Columtiia  Wini\3tv^itf       [ 
in  ttie  Citp  of  ^cto  gorfe 

College  of  l^\)piitmn&  anh  burgeons! 


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COXTEIBLTORS  TO  VOLUME  I. 

ABBE,  ROBERT,  M.D. 

BECK,  JOSEPH  C,  M.D.,  F.A.C.S. 

BROWN,    GEORGE    VAX  IXGEX,    A.B.,    D.D.S.,  M.D., 
F.A.C.S. 

CRILE,  GEORGE  W.,  A.M.,  M.D.,  F.A.C.S.,  F.R.C.S.  (Hon.) 

CUSHIXG,  HARVEY,  M.D.,  Sc.D.,  F.R.C.S. 

GIBBOX,  JOHX  H.,  M.I). 

JACKSOX,  CHEVALIER,  M.D. 

JOXAS,  A.  F.,  M.D. 

KAHLE:E,  CHARLES  EDWIX,  B.S.,  M.D.,  F.A.C.S. 

KAXAVEL,  ALLEN  B.,  M.D. 

NUZUM,  JOHN  W.,  S.B.,  M.D. 

OCHSNER,  ALBERT  J.,  M.D.,  LL.D.,  F.A.C.S.,  F.R.M.S. 

PERCY,  NELSON  MORTIMER,  M.D.,  F.A.C.S. 

SCKMIDT,  EDWIN  R.,  B.A.,  M.D. 

SCIBIITZ,  HENRY',  A.M.,  M.D.,  F.A.C.S. 

SHA^IBAUGH,  GEORGE  E.,  M.D. 

STANTON,  E.  MacD.,  B.Sc,  M.D.,  F.A.C.S. 

TINKER,  MARTIN  B.,  M.D. 


SUEGICAL 


DIAGNOSIS  AND  TREATMENT 


BY  AMERICAN  AUTHORS 


EDITED  BY 

ALBERT  J.  OCHSNER,  M.D.,  LL.D.,  F.A.C.S.,  F.R.M.S. 

PROFESSOR    OF    SURGERY   IN   THE    MEDICAL   DEPARTMEJTT   OF   THE    UNIVERSITY   OF   ILLINOIS; 

SURGEON-IN-CHIEF  TO  THE    AUGUSTANA  ANT)   ST.  MARY's   HOSPITALS, 

CHICAGO,  ILL. 


ILLUSTRATED    WITH  562   ENGRAVINGS  AND 
15  COLORED    PLATES 


VOLUME   I 


LEA   &   FEBIGER 

PHILADELPHIA  AND  NEW  YORK 
1920 


COPTKIGHT 

LEA  &   FEBIGER 
1920 


PREFACE. 


The  professional  careers  of  the  present  leaders  in  sm-gery  represent 
a  period  of  advance  in  methods  of  diagnosis  and  treatment  unequalled 
by  the  progress  of  many  previous  centuries.  The  atmosphere  of 
spiritual  and  material  progress  in  which  they  li^•e  enables  these  men 
to  abandon  precedent  and  accept  new  ideas.  To  them  must  be  credited 
the  introduction,  the  development  and  the  adoption  of  many  inno- 
vations far  beyond  the  imagination  of  their  predecessors.  Their  unself- 
ish dcA'otion  deserves  and  receives  world-wide  recognition.  Therefore, 
it  has  seemed  eminently  proper  to  collect  and,  in  their  own  language,  to 
record  in  these  volumes  the  conclusions  of  this  group  of  contemporary 
workers  who  have  so  splendidly  utilized  their  unusual  opportunities 
to  enrich  surgical  knowledge. 

At  the  present  time  it  is  deemed  especially  desirable  to  publish  a 
comprehensive  work  emphasizing  both  surgical  diagnosis  and  treat- 
ment; because,  on  the  part  of  the  surgeon,  there  haA'e  lately  been  signs 
of  relaxation  on  the  side  of  diagnosis.  To  neglect  the  application  of 
any  resource  in  this,  its  most  difficult  department,  would  soon  lose  for 
surgery  the  en^dable  position  won  for  it  by  the  tireless  efforts  of  a 
generation. 

This  work  in  every  sense  reflects  the  current  practice  and  thought  of 
the  most  intensely  active  sm'geons  of  this  continent.  Its  chapters 
endeavor  to  teU  the  ichy  and  how  in  the  solution  of  each  surgical 
problem,  and  to  bring  the  reader  in  touch  with  the  actual  experience, 
reasoning  and  practical  methods  of  men  eminent  in  all  parts  of  the 
country.  Each  one  describes  intimately  his  methods  of  diagnosis,  his 
plans  for  treatment  before  and  after  operation  and  gives  his  judgment 
regarding  them. 

The  reader  may  feel  assured  that  he  will  find  nothing  here  that 
smacks  of  what  is  copied  from  text-books;  but  only  fresh  material  that 
represents  the  living  work  of  today  done  by  those  whose  powers  of 
observation  make  their  conclusions  worthy  of  confidence.  So  far  as 
possible,  duplication  has  been  avoided  on  the  one  hand,  and  on  the 
other  an  attempt  has  been  made  to  cover  the  entire  field  of  general 

(v) 


vi  PREFACE 

surgery.     Specialties  have  been  invaded  only  so  far  as  the  general 
surgeon  is  justified  in  going  when  special  skill  is  unavailable. 

In  greater  part  the  articles  have  been  prepared  during  the  strenuous 
years  of  the  world  war,  which  rendered  the  labor  more  arduous  for 
contributors  and  publishers  alike,  but  it  has  added  immeasurably  to 
the  value  of  the  work.  With  the  exception  of  a  few  whose  duties  as 
teachers  held  them  at  their  posts,  all  of  the  contributors  were  in  the 
medical  service  of  the  Allied  armies,  and  the  material  relating  to  war 
surgery  has  been  written  from  the  abundance  of  their  recent  experience. 

The  editor  desires  to  express  his  appreciation  of  the  courtesies 
extended  to  him  by  all  contributors  as  well  as  by  the  publishers.  He 
especially  wishes  gratefully  to  record  his  obligation  for  help  received 
from  his  assistants,  Drs.  Dennis  W.  Crile,  Frank  H.  Doubler,  O.  E. 
Nadeau,  John  W.  Xuzum  and  Erwin  R.  Schmidt. 

A.  J.  O. 
Chicago,  1920. 


CONTRIBUTORS. 


ROBERT  ABBE,  M.D., 

Senior  Surgeon  at  St.  Luke's  Hospital;  Consulting  Surgeon  to  the  Roosevelt, 
the  Woman's,  the  Hospital  for  Ruptured  and  Crippled  and  the  Babies' 
Hospitals,  New  York  City;  Associate  Fellow  of  the  College  of  Physicians  of 
Philadelphia,  etc. 

JOSEPH  C.  BECK,  M.D.,  F.A.C.S., 

Associate  Professor  of  Otolarjragology  in  the  University  of  Illinois,  Chicago, 
in.;  Attending  Otolaryngologist  to  the  Cook  County  Hospital  and  the 
North  Chicago  Hospital,  Chicago,  111. 

GEORGE  VAN  INGEN  BROWN,  A.B.,  D.D.S.,  M.D.,  F.A.C.S., 

Lieutenant-Colonel,  Medical  Reserve  Corps,  U.  S.  Army;  Surgeon,  U.  S. 
Public  Health  Service,  and  Consultant  in  Plastic  Surgery,  U.  S.  Pubhc 
Health  Service  at  Milwaukee;  Plastic  and  Oral  Surgeon  to  St.  Mary's 
Hospital  and  to  the  Children's  Free  Hospital  and  Columbia  Hospital, 
Milwaukee,  Wis.;  Fellow  of  the  American  Medical  Association;  Member 
of  the  National  Dental  Association;  Chairman  of  the  Section  on  Oral 
Surgery  of  the  Fourth  International  Dental  Congress,  etc.;  formerly  in 
charge  of  the  Sub-section  of  Plastic  and  Oral  Surgery  of  the  Head  Surgery 
Division  of  the  Office  of  the  Surgeon-General;  Chief  of  the  Maxillofacial 
Service  at  Walter  Reed  Hospital,  Takoma  Park,  Washington,  D.  C. 

GEORGE  W.  CRILE,  A.M.,  M.D.,  F.A.C.S.,  F.R.C.S.  (Hon.), 

Professor  of  Surgery  in  the  Western  Reserve  University,  Cleveland,  Ohio; 
Visiting  Surgeon  to  the  Lakeside  Hospital,  Cleveland,  Ohio. 

HARVEY  GUSHING,  M.D.,  ScD.,  F.R.C.S., 

Professor  of  Sm-gery  in  the  Harvard  University;  Surgeon-in-Chief  to  the  Peter 
Bent  Brigham  Hospital,  Boston,  Mass. 

JOHN  H.  GIBBON,  M.D., 

Professor  of  Surgery  in  the  Jefferson  Medical  College,  Philadelphia;  Surgeon 
to  the  Pennsylvania  and  Jefferson  Hospitals,  Philadelphia,  and  Consulting 
Surgeon  to  the  Bryn  Mawr  Hospital,  Bryn  Mawr,  Pa.;  Late  Colonel  in  the 
Medical  Corps  of  the  United  States  Army. 

CHEVALIER  JACKSON,  M.D., 

Professor  of  Laryngology  in  the  Jefferson  Medical  College,  Philadelpliia. 

A.  F.  JONAS,  M.D., 

Head  of  Surgery  in  the  Medical  Department  of  the  State  University;  Surgeon 
at  the  Nebraska  State  University  Hospital,  the  Nebraska  Methodist  Episco- 
pal Hospital,  and  the  Wise  Memorial  Hospital,  Omaha,  Neb.;  Chief  Surgeon 
of  the  Union  Pacific  Railroad,  Omaha,  Neb. 

CHARLES  EDWIN  KAHLKE,  B.S.,  M.D.,  F.A.C.S., 
Chicago,  111. 

(vii) 


viii  CONTRIBUTORS 

ALLEN  B.  KANAVEL,  M.D., 

Professor  of  Surgery  in  the  Northwestern  University  Medical  School; 
Attending  Surgeon  at  the  Wesley  Memorial  and  Cook  County  Hospitals, 
Chicago,  111.  • 

JOHN  W.  NUZUM,  S.B.,  M.D., 

Associate  in  Anatomy  and  Pathology  in  the  University  of  Illinois,  College  of 
Medicme,  Chicago;  Chief  Surgical  Assistant  to  Drs.  A.  J.  Ochsner  and 
Nelson  Percy  at  Augustana  Hospital,  Chicago;  formerly  Director  of  the 
Laboratories  in  the  Cook  County  Hospital,  Chicago,  111, 

ALBERT  J.  OCHSNER,  M.D.,  LL.D,  F.A.C.S,  F.R.M.S., 

Professor  of  Surgery  in  the  Medical  Department  of  the  University  of  Illinois; 
Surgeon-in-Chief  to  the  Augustana  and  St.  Mary's  Hospitals,  Chicago,  111. 

NELSON  MORTIMER  PERCY,  M.D.,  F.A.C.S., 

Associate  Professor  of  Clinical  Surgery  in  the  University  of  IlUnois  College  of 
Medicine,  Chicago;  Attending  Surgeon  to  the  Augustana  and  St.  Mary's 
Hospitals,  Chicago,  III;  Fellow  of  the  American  Surgical  Association. 

EDWIN  R.  SCHMIDT,  B.A.,  M.D., 

Chief  of  Resident  Staff  of  the  Augustana  Hospital,  Chicago,  111.;  Captain, 
Medical  Corps,  U.  S.  Army. 

HENRY  SCHMITZ,  A.M.,  M.D.,  F.A.C.S., 

Professor  and  Head  of  the  Department  of  Gynecology  in  the  Loyola  University 
School  of  Medicine;  Attending  Surgeon  at  St.  Mary's  of  Nazareth  Hospital; 
Attendmg  Gynecologist  at  the  Cook  County  Hospital  and  the  Frances  E. 
WiUard  National  Temperance  Hospital,  Chicago,  111. 

GEORGE  E.  SHAMBAUGH,  M.D., 

Professor  of  Otology  and  Laryngology  in  the  Rush  Medical  College;  Otologist 
to  the  Presbyterian  Hospital,  Chicago,  III. 

E.  MacD.  STANTON,  B.Sc,  M.D.,  F.A.C.S., 

Surgeon  to  the  Ellis  Hospital,  Schenectady,  New  York. 

MARTIN  B.  TINKER,  M.D., 

Lieut.-Colonel  in  the  Medical  Reserve  Corps  of  the  United  States  Army; 
Chief  of  Surgical  Service  at  the  U.  S.  General  Hospital  No.  26,  Fort  Des 
Moines,  Iowa;  Formerly  Assistant  Professor  of  Surgery  at  Cornell  Univer- 
sity, Ithaca,  New  York. 


CONTENTS. 


SURGICAL  PROGNOSIS 17 

By  E.  MacD.  Stanton,  B.Sc,  M.D.,  F.A.C.S. 

TECHNICAL  EFFICIENCY 77 

By  Albert  J.  Ochsner,  M.D.,  LL.D.,  F.A.C.S.,  F.R.M.S. 

ASEPTIC  AND  ANTISEPTIC  TECHNIC 79 

By  Albert  J.  Ochsner,  M.D.,  LL.D.,  F.A.C.S.,  F.R.M.S. 

ANESTHETICS  AND  ANESTHESIA 93 

By  Edwin  R.  Schmidt,  B.A.,  M.D. 

SHOCK  AND  HEMORRHAGE 117 

By  John  W.  Nuzum,  S.B.,  M.D. 

INFLAMMATION  AND  HEALING  OF  WOUNDS 125 

By  John  W.  Nuzum,  S.B.,  M.D. 

SURGICAL  FEVER  AND  INFECTIONS 131 

By  John  W.  Nuzum,  S.B.,  M.D. 

POSTOPERATIVE  TREATMENT 139 

By  John  H.  Gibbon,  M.D. 

VACCINES    . 163 

By  a.  F.  Jonas,  M.D. 

BLOOD  TRANSFUSION 187 

By  Nelson  Mortimer  Percy,  M.D.,  F.A.C.S. 

EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE     ....      209 
.'  By  Robert  Abbe,  M.D. 

DEEP  ROENTGENTHERAPY 235 

By  Henry  Schmitz,  A.M.,  M.D.,  F.A.C.S. 

(ix) 


X  CONTENTS 

INJURIES  AND  DISEASES  OF  THE  SKULL  AND  ITS  COVERINGS    263 
By  Charles  Edwin  Kahlke,  B.S.,   M.D.,  F.A.C.S. 

DIAGNOSIS  AND  TREATMENT  OF  TUMORS,  INFLAMMATIONS 

AND  ABSCESSES  OF  THE  BRAIN 327 

By  Allen  B.  Kanavel,  M.D. 

THE  PURPOSE  AND  TECHNICAL  STEPS  OF  A  SUBTEMPORAL 

DECOMPRESSION 407 

By  Harvey  Cushing,  M.D.,  Sc.D.,  F.R.C.S. 

SURGICAL  COMPLICATIONS  RESULTING  FROM  SUPPURATIVE 

MIDDLE-EAR  DISEASE 449 

By  George  E.  Shambaugh,  M.D. 

SURGERY  OF  THE  NOSE  AND  THROAT 473 

By  Joseph  C.  Beck,  M.D.,  F.A.C.S. 

SURGERY  OF  THE  MOUTH  AND  FACE 535 

By  George  Van  Ingen  Brown,  A.B.,  D.D.S.,  M.D.,  F.A.C.S. 

MAJOR  OPERATIONS  ON  THE  MOUTH 655 

By  Albert  J.  Ochsner,  M.D.,  LL.D.,  F.A.C.S.,  F.R.M.S. 

SURGERY  OF  THE  NECK 669 

By  Martin  B.  Tinker,  M.D. 

DIRECT    LARYNGOSCOPY,  BRONCHOSCOPY  AND  ESOPHAGOS- 

COPY 735 

By  Chevalier  Jackson,  M.D. 

SURGICAL  DISEASES  OF  THE  THYROID  AND   PARATHYROID 

GLANDS 771 

By  Nelson  Mortimer  Percy,  M.D.,  F.A.C.S. 

THE  DUCTLESS  GLANDS 811 

By  George  W.  Crile,  A.M.,  M.D.,  F.A.C.S.,  F.R.C.S.  (Hon.) 

SURGERY  OF  THE  THYMUS  GLAND 821 

By  Albert  J.  Ochsner,  M.D.,  LL.D.,  F.A.C.S.,  F.R.M.S. 


SUEGICAL  PEOGXOSIS. 

By  E.  MacD.  STANTON,  M.D.,  F.A.C.S. 

In  surgery  the  relation  bet"^'een  cause  and  effect,  the  operation  and 
its  result,  is  usually  so  definite  that  the  subject  of  prognosis  assumes 
a  position  of  far  greater  relative  importance  than  in  most  other 
branches  of  medicine.  A  thorough  knowledge  of  surgical  prognosis 
is  the  most  essential  single  requisite  for  a  sound  siu'gical  judgment, 
and,  no  matter  how  great  the  surgeon's  diagnostic  ability  or  how 
excellent  his  operative  technic,  his  ultimate  standing  as  a  surgeon 
will  be  determined  very  largely  by  the  standard  of  surgical  judgment 
which  characterizes  his  work. 

^Yhen  we  attempt  to  deal  with  the  general  aspects  of  surgical  prog- 
nosis it  is  well  for  us  to  bear  in  mind  that  there  are  two  distinct  mental 
processes  by  which  the  surgeon  may  arrive  at  the  approximate  prognosis 
of  the  individual  case. 

First,  he  may  ascertain  the  results  previously  obtained  in  similar 
cases,  beginning  with  the  average  results  obtained  in  all  those  indi- 
viduals who  have  suffered  from  the  same  disease  and  proceeding 
ultimately  to  the  results  obtained  in  smaller  groups  of  cases  more 
nearly  approaching  in  their  various  details  the  character  of  the  case 
under  consideration.  This  first  or  comparative  method  necessitates 
an  intimate  knowledge  of  the  statistical  data  having  to  do  with  the 
prognosis  of  each  separate  disease.  The  specific  portions  of  our 
knowledge  concerning  this  phase  of  prognosis  are  far  too  complex  in 
their  detail  to  be  encompassed  in  the  limits  of  this  chapter. 

The  second  method  depends  chiefly  upon  a  careful  study  of  the 
individual  patient  with  special  reference  to  each  one  of  those  factors 
which  may  be  ascertained  to  have  a  distinct  bearing  on  the  outcome 
of  the  case.  These  factors,  which  haA-e  to  do  principally  with  the 
general  condition  of  the  patient  and  the  dangers  and  complications 
incident  to  all  surgical  diseases  and  operations,  can  be  discussed  to 
advantage  in  a  chapter  devoted  expressly  to  this  piu"pose. 

STATISTICS   IN   PROGNOSIS. 

Because  statistics  play  such  an  important  part  in  all  discussions 
pertaining  to  the  subject,  it  may  be  well  to  emphasize  several 
facts  concerning  the  value  of  and  the  limitations  of  statistics  in 
prognosis.  Statistics  properly  handled  are  essential  for  determining 
many  of  the  most  important  truths  concerning  prognosis.  That 
2  (17) 


18  SURGICAL   PROGNOSIS 

they  are  not  always  properly  interpreted,  and  that  both  medicine 
and  surgery  have  been  abundantly  burdened  with  figures  of  doubtful 
or  even  negative  value  means  only  that  due  care  should  be  used  in 
drawing  conclusions  from  this  kind  of  data.  The  man  with  a  thorough 
knowledge  of  the  subject  at  hand  and  a  fair  sense  of  mathematical 
proportion  usually  finds  little  difficulty  in  ascertaining  the  important 
points  demonstrated  by  the  statistical  data  presented. 

The  most  common  error  arising  from  the  use  of  medical  as  well  as 
other  statistics  comes  from  a  failure  to  recognize  the  fact  that  gener- 
alities, no  matter  how  true  they  may  be  in  themselves,  are  not  meant 
to  be  applied  directly  to  specific  instances.  For  example,  statistics 
collected  from  all  over  the  world  show  that,  taken  as  a  whole,  the 
operative  mortality  in  acute  appendicitis  has  borne  a  quite  definite 
relationship  to  the  day  of  the  disease  on  which  the  patient  has  been 
operated.  That  these  figures  do  show  certain  great  truths  concerning 
the  mortality  of  acute  appendicitis  is  proved  by  the  fact  that  the 
results  are  essentially  uniform  for  large  groups  of  cases  compiled  from 
clinics  in  no  way  connected  with  one  another.  Yet  because  there 
has  been  an  average  mortality  of  say  S  per  cent,  for  patients  subjected 
to  operation  during  the  third  day  of  the  acute  attack,  it  does  not 
mean  that  this  figure  represents  the  true  prognosis  in  the  majority  of 
individual  third-day  appendix  cases.  As  a  matter  of  fact  a  perfectly 
accurate  individual  prognosis  under  the  circumstances  existing  at  the 
time  the  patients  were  operated  upon  would  have  been  wholly  favor- 
able in  92  per  cent,  of  the  cases,  and  entirely  unfavorable  in  8  per 
cent.  The  absm-dity  of  predicting  one  chance  in  twelve  of  death 
for  each  individual  third-day  appendix  case  because  that  may  have 
been  the  average  for  cases  operated  during  the  third  day  of  the  attack 
is  self  evident. 

It  is  a  fact  to  be  regretted  that  much  of  the  available  data  purporting 
to  show  the  results  obtained  in  the  many  special  fields  of  surgery  has 
emanated  from  the  clinics  of  those  who  have  devoted  particular 
attention  and  skill  to  the  special  line  of  work,  the  results  of  which, 
they  have  reported.  Just  in  so  far  as  these  reports  represent  the 
exceptional  rather  than  the  average  results  they  are  liable  to  be 
misleading.  Such  statistics  should  be  interpreted  as  representing 
what  can  be  accomplished  under  exceptional  cu-cumstances  rather 
than  as  a  fair  estimate  of  the  results  to  be  expected  under  ordinary 
conditions.  The  true  prognosis  and  the  permanent  standing  of  a 
surgical  procedure  are  determined  not  by  the  exceptional  results 
which  may  be  obtained  by  some  master  in  a  particular  line  of  work, 
but  by  the  average  results  which  are  obtained  by  other  surgeons 
using  the  same  methods. 

The  introduction  of  a  standard  case-record  system  for  hospitals 
complying  with  the  standardization  requirements  of  the  American 
College  of  Surgeons  has  been  a  notable  advance  which  is  bound  to 
result  in  the  accumulation  of  much  needed  data  pertaining  to  the  sub- 
ject of  surgical  prognosis.    The  summary  card  recommended  by  the 


STATISTICS  IN  PROGNOSIS  19 

College  is  admirably  adopted  to  the  purpose  of  collecting  end-result 
data. 

Data  as  to  end-results  is  best  attained  by  means  of  letters  sent  to 
the  patients  at  regular  intervals  following  the  operation.  In  the  case 
of  general  hospitals  treating  large  numbers  of  charity  patients  the  pro- 
portion of  answers  received  to  these  letters  is  often  disappointing.  On 
the  other  hand  in  private  practice  we  have  for  a  number  of  years 
received  more  than  90  per  cent,  of  replies  to  the  following  letter: 

Schenectady,  N.  Y. 

"It  is  now  just  a  year  since  your  operation,  and  as  I  am  anxious  to  keep  track  of 
the  results  obtained  in  all  cases  operated  by  me,  I  will  appreciate  the  favor  if  you  will 
fill  out  the  answers  to  the  following  questions  and  return  this  letter  in  the  enclosed 
stamped  envelope. 

After  the  operation  were  you  cured  of  the  trouble  from  which  you  sought  relief? 

If  cured,  how  long  after  the  operation  was  it  before  you  recovered  your  strength? 
If  not  entirely  cured,  what  symptoms  referable  to  the  old  condition  still  persist? 

Were  there  any  ill  effects  referable  to  the  operation  itself? 

If  so  describe  briefly  what  they  were 

Please  note  any  other  points  of  interest  concerning  the  results  of  your  operation 
not  covered  by  the  above  questions 

If  you  are  not  certain  concerning  the  answers  to  the  above  questions  you  can  call 
on  your  family  physician  for  advice  or  you  can  telephone  me  or  call  at  my  office  at 
any  time  during  office  hours. 

Very  sincerely," 


The  system  introduced  by  the  American  College  of  Surgeons  is 
resulting  in  the  collection  of  an  enormous  amount  of  data  pertaining 
to  the  late  results  following  operations.  However  my  own  end-result 
studies,  carried  out  over  a  period  of  thirteen  years,  have  convinced  me 
that  the  chief  reason  for  our  present-day  lack  of  end-result  knowledge 
is  not  so  much  the  lack  of  data  as  that  surgeons  have  not  as  yet 
devised  a  uniform  and  satisfactory  system  for  reporting  the  data 
which  they  have  been  able  to  collect.  Surgical  literature  is  full  of  com- 
munications dealing  in  a  general  way  with  the  subject  of  end-results, 
in  which  it  is  evident  that  the  author  is  in  possession  of  considerable 
data  which  he  has  finally  despaired  of  presenting  in  other  than  the 
most  general  terms. 

Some  time  ago  I  found  that  I  had  several  thousand  histories  with 
end-result  records  extending  over  fairly  adequate  periods  of  time, 
but  that  whereas  these  records  had  been  collected  with,  let  us  say,  one 
unit  of  energy  on  my  part,  when  I  came  to  study  any  one  group  of 
cases  it  took  several  units  of  time  and  energy  to  put  the  data  into  form 
suitable  for  study  and  comparison.  In  some  groups  it  was  impossible 
to  classify  the  results  according  to  the  usually  attempted  standards. 
Also,  I  found  that  no  two  surgeons  adopted  the  same  standards  in 
reporting  their  cases,  so  that  it  was  impossible  to  compare  small  groups 
from  different  sources  or  to  combine  them  into  larger  series  of  greater 
statistical  value. 


20 


SURGICAL  PROGNOSIS 


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STATISTICS  IN  PROGNOSIS 


21 


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24 


SURGICAL  PROGNOSIS 


The  real  reason  for  this  difficulty  lies  in  the  fact  that  surgeons  have 
tried  to  state  the  end-results  in  terms  such  as  "cured,"  "improved," 
etc.,  ^vithout  reference  to  the  time  element.  Actually,  our  patients 
are  cured,  or  whatever  the  result  may  be,  for  variable  periods  of  time, 
and  it  is  just  as  absurd  to  try  to  state  end-results  in  terms  ignoring  the 
element  of  time  as  it  would  be  to  attempt  to  state  the  area  of  a  plot 
of  ground  in  terms  of  one  dimension. 

All  of  the  major  difficulties  of  presenting  the  end-results  disappear 
if  we  tabulate  the  results  in  terms  of  the  time  the  patients  have  been 
traced  following  the  operation,  together  with  their  state  of  health  for 
the  time  periods.  By  this  method  the  "  cured"  column  becomes  "  years 
cured"  and  the  term  "years"  is  also  added  to  the  other  divisions.  It 
is  also  of  advantage  to  add  the  headings  "years  operated"  and  "years 
traced"  as  illustrated  in  the  accompanying  table,  which  shows  the 
results  of  tabulating  26  exophthalmic  goitre  cases  operated  by  myself. 

The  mortality  may  be  recorded  either  as  "years  dead"  or  by  simply 
giving  the  number  of  deaths.  In  the  cases  here  reported  the  operative 
and  late  deaths  are  given  in  separate  columns,  also  the  expected  mor- 
tality in  normal  individuals  for  the  same  period  is  indicated. 

TABLE  I. — RESULTS  FOLLOWING  OPERATIONS  FOR  EXOPHTHALMIC 

GOITER. 


Case 
No. 


Years 
op. 


Years 
traced. 


Years 
cured. 


Years 

satis-  Years 

factorily    improved 
improved. 


Years 
unim- 
proved. 


Deaths. 


Imme- 
diate. 


Late. 


2 

10 

3 

3 

10 

10 

4 

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9 

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1 

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13 

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16 

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18 

5  8/l2 

49/12 

19 

5  6/k 

56/12 

21 

5  Vl2 

5Vl2 

28 

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3'/l2 

30 

39/12 

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32 

36/12 

36/12 

33 

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3Vl2 

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41 

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1 

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44 

19/12 

1V12 

45 

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1 

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1 

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6/12 


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1 

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1 

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1 

Total       136  V12       107  Vis       50  Vu  20^12         22^ln 


26/l2 


THE  PROGNOSIS  OF  ALL  SURGICAL  DISEASES  25 

The  advantages  of  this  system  of  recording  end-results  are  quite 
obvious.  No  matter  how  complicated  the  postoperative  history,  it  can 
be  readily  subdivided  and  classified  into  the  appropriate  periods. 

It  is  not  necessary  for  the  surgeon  to  trace  each  case  to  the  time  of 
reporting  his  results.  If  he  has  lost  track  of  his  patient  soon  after 
operation  this  fact  is  clearly  shown  by  his  figures  and  the  value  of  the 
data  may  be  judged  accordingly.  This  method  of  completmg  end- 
result  statistics  is  illustrated  by  Table  I. 

Formerly  the  most  difficult  of  all  cases  to  classify  were  the  exoph- 
thalmic goiter  cases.  This  was  because  almost  no  single  case  could  be 
placed  under  a  single  heading.  By  the  method  here  outlined  even  the 
exophthalmic  goiter  cases  can  be  readily  classified.  The  table  shows  26 
cases  operated,  a  total  of  136yV  years  and  traced  107 j^  years.  Of 
this  time  oOyV  years  or  47  per  cent.,  of  the  total  traced  postoperative 
time  the  patients  have  been  cured.  An  additional  20x2"  years,  or 
9  per  cent.,  of  the  time  the  patients  have  been  satisfactorily  improved, 
making  66  per  cent,  of  truly  satisfactory  results.  22yV  years,  or  21 
per  cent.,  credited  in  the  improved  column,  represent  improvement 
to  such  an  extent  that  the  patients  feel  well  repaid  for  their  operations. 
Only  2yV  years,  or  2  per  cent,  of  the  postoperative  time,  has  been 
passed  as  unimproved. 

In  this  series  there  are  3  early  postoperative  and  2  late  deaths.  The 
expected  mortality  for  normal  risks  of  the  average  age  of  the  patients 
in  this  series  is  0.963,  or  not  quite  1  normally  expected  death. 

GENERAL  FACTORS   INFLUENCING   THE   PROGNOSIS   OF 
ALL   SURGICAL  DISEASES. 

Age. — The  influence  of  age  on  surgical  prognosis  is  most  important 
at  the  two  extremes  of  life.  The  fact  that  the  effect  of  age  on  the 
mortality  of  surgical  diseases  is  essentially  the  same  as  the  effect  of 
age  on  disease  in  general  enables  us  to  make  use  of  the  enormous  data 
collected  by  life  insurance  companies.  Chart  I  has  been  compiled 
from  the  standard  mortality  tables  of  the  life  insurance  companies 
for  the  purpose  of  graphically  representing  the  effect  of  age  on  mor- 
tality. Although  the  data  used  for  these  tables  is  not  obtained  from 
surgical  experience  we  believe  that  the  curves  here  reproduced  do 
show  better  than  any  other  data  available  the  effect  of  age  per  se 
upon  the  mortality  factor  in  surgical  prognosis. 

An  infant  during  the  first  year  of  life  is  a  poor  surgical  risk.  In 
general  mortality  statistics,  most  of  the  deaths  are  due  to  nutritional 
disorders  not  directly  associated  with  surgical  conditions,  but  never- 
theless infants  suffering  from  surgical  diseases  demanding  operations 
at  this  early  age  are  usually  in  a  condition  making  them  particularly 
liable,  not  only  to  the  dangers  incident  to  the  operation  itself,  but  to 
all  the  incidental  dangers  of  this  delicate  age  as  well. 

The  general  mortality  of  the  second  year  is  only  about  one-fourth 
that  of  the  first  year,  and  the  prognosis  continues  to  improve  until. 


26 


SURGICAL  PROGNOSIS 


at  about  six  years  of  age,  the  special  dangers  of  early  infancy  and 
childhood  have  largely  disappeared.  Nevertheless,  actuarial  figures 
show  a  continued  improvement  up  to  the  age  of  twelve.  The  mor- 
tality from  all  causes  during  the  years  from  ten  to  fifteen  is  decidedly 
less  than  in  any  other  period  of  years  allotted  to  man. 

Before  passing  to  the  consideration  of  the  middle  and  later  periods 
of  life,  it  may  be  well  to  mention  certain  points  of  special  surgical 
importance  having  a  bearing  on  the  prognosis  of  the  early  years  of  life. 


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Fig.  1. — -Relation  of  age  to  mortality  risk. 

Surgeons  generally  agree  that  children,  and  especially  infants,  bear 
hemorrhage  badly.  Yet  when  we  take  into  consideration  the  natur- 
ally bloody  character  of  a  large  proportion  of  the  operations  of  general 
surgery  undertaken  on  infants  and  children,  and  the  proportionate 
amounts  of  blood  available  for  loss  in  children  and  adults,  it  is  diffi- 
cult to  prove  a  much  greater  relative  inability  to  withstand  hemorrhage 
in  the  younger  patients.  Certainly  in  the  absence  of  other  factors  to 
produce  or  continue  shock,  the  recovery  of  the  average  child  from  the 
effects  of  hemorrhage  after  such  operations  as  tonsillectomy  or  staphyl- 
orrhaphy is  very  rapid. 

Nearly  all  surgeons  agree  that  children  are  particularly  susceptible 
to  shock,  and  this  fact  should  always  be  borne  in  mind  when  operating 
on  children.     Nevertheless,  operative  interference  of  such  magnitude 


THE  PROGNOSIS  OF  ALL  SURGICAL  DISEASES  27 

as  to  be  commonly  associated  with  serious  shock  is  seldom  really 
imperative  during  childhood.  In  cases  requiring  extensive  operative 
work  the  conditions  are  usually  such  that  all  need  not  be  done  at 
one  time.  Children  much  better  than  adults  can  afford  the  extra 
time  consimied  by  operations  carried  out  in  several  stages. 

The  susceptibility  of  the  yoimg  baby  to  all  those  conditions  inter- 
fering with  its  nutrition  is  known  to  all  mothers,  and  the  intensity 
of  the  metabolic  processes  throughout  childhood  make  children,  as  a 
rule,  more  susceptible  than  adults  to  interference  with  their  nutri- 
tion. Yet,  if  children  are  not  too  unruly,  those  suffering  from  intra- 
peritoneal infections  may  be  kept  for  a  week  or  more  on  the  jMurphy 
drip,  without  food  or  drink  by  mouth,  and  after  the  cause  of  their 
illness  has  been  successfully  dealt  with,  it  is  remarkable  how  quickly 
they  regain  their  weight  and  strength. 

The  prognosis  of  surgical  tuberculosis  is  very  much  better  in  chil- 
dren than  in  adults.  If  the  part  can  be  kept  at  rest,  bone  tuberculosis, 
as  a  rule,  heals  spontaneously  in  children,  while  in  adults  radical 
excision  of  the  diseased  structures  is  usually  required  in  order  to 
effect  a  cure.  LATnph  gland  tuberculosis  in  children  heals  sponta- 
neously or  after  the  simple  removal  of  the  more  extensively  involved 
glands,  while  in  adults  recurrences  after  operation  for  tuberculous 
lymph  nodes  are  the  rule,  unless  all  of  the  glands  in  the  region  of  the 
involvement  are  removed  as  well  as  the  focus  of  primars'  infection  in 
the  tonsils  or  elsewhere. 

In  children  the  increased  risks  due  to  alcoholism  and  other  excesses 
may  be  eliminated  from  our  reckoning. 

The  child  recovers  very  rapidly  from  the  nervous  phenomena 
accompanying  the  operation  and  postoperative  nem"asthenia  is  almost 
never  seen. 

Thrombosis  and  embolism  are  very  rare  after  operations  during 
childliood. 

Dm-ing  middle  life  the  mortality  cm-ve  shows  a  gradually  increasing 
risk  with  each  succeeding  year  until  in  the  forties  the  curve  begins 
to  ascend  more  rapidly.  It  is  well  to  note  that  between  forty-five 
and  fifty-five  years  there  is  practically  a  60  per  cent,  increase  in  the 
male  mortality  rate.  These  are  the  years  which  represent  the  period 
of  the  menopause  in  women.  It  is  "the  critical  period  for  women" 
in  the  minds  of  the  laity  and  most  of  the  profession.  But  a  careful 
examination  of  the  table  shows  the  rise  in  female  mortality  diu-ing 
this  period  is  just  as  gradual  as  it  was  before.  ]Much  more  startling 
is  the  appearance  of  the  increase  in  the  male  mortality.  Certainly 
this  is  man's  critical  period.  The  old  doctrine  that  he  too  had  a  great 
climacteric  is  most  strikingly  shown.  In  the  ten  years  from  forty-six 
to  fifty-six  the  gain  in  mortality  per  mille  per  annum  for  males  is  6.32, 
while  for  females  it  is  only  3.47.  What  are  the  causes  for  this  greatly 
increased  mortality  among  men?  It  is  because  his  dissipations  now 
begin  to  make  themselves  felt — especially  alcoholism.  The  sA'philis 
of  his  youth  is  just  drawing  its  last  check.     The  hardships  of  his 


28  SURGICAL  PROGNOSIS 

occupation  have  now  begun  to  bankrupt  him.  This  is  the  period 
when  habits  and  excesses  begin  to  have  a  special  importance  in  surgical 
prognosis. 

After  fifty  the  normal  death-rate  increases  so  rapidly  that  it  is 
l)ractically  doubled  with  each  succeeding  decade.  Thus,  at  fifty  it 
is  13.01  per  mille  for  males,  at  sixty  it  is  23.67,  at  seventy  it  is  55.64 
and  at  eighty  124.93,  or  at  the  latter  age  approximately  twenty  times 
the  normal  death-rate  for  fifteen  years  of  age. 

In  those  past  middle  life,  the  effects  of  age  on  the  individual  prog- 
nosis must  be  estimated  in  conjunction  with  a  knowledge  of  such 
ascertainable  facts  as  the  blood-pressure,  the  general  condition  of  the 
heart  and  arteries,  the  findings  of  the  urinary  examination  and  the 
previous  habits  of  the  patient. 

Sex. — The  sex  of  the  patient  concerns  more  closely  the  incidence 
than  it  does  the  prognosis  of  surgical  diseases.  Most  surgeons  are 
convinced  that  women  are,  as  a  rule,  better  risks  than  men,  and 
there  is  considerable  data  purporting  to  show  that  the  operative 
mortality  in  diseases  of  certain  organs  not  related  to  the  sex  of  the 
patient,  e.  g.,  gall-bladder  surgery,  is  very  much  higher  in  the  male 
than  in  the  female.  A  study  of  this  data,  however,  seems  to  show  that 
the  increased  mortality  in  men  occurs  chiefly  in  the  surgery  of  organs 
liable  to  be  damaged  by  alcoholism  and  other  excesses,  and  that  males 
whose  general  resistance  has  not  been  undermined  by  irregular  living 
are  quite  as  good  risks  as  females.  Women  are  much  less  likely  to 
be  handicapped  by  these  excesses. 

The  other  noteworthy  effects  of  sex  on  the  prognosis  have  to  do 
with  the  conditions  involving  especially  the  sex  organs  and  will  be 
discussed  under  the  diseases  of  these  organs. 

Constitution. — As  regards  operative  mortality  there  is  little  to 
choose  between  the  slender,  weak-muscled,  nervous  patient  and  the 
heavy,  strong-muscled,  calm,  physically  perfect  individual.  If  any- 
thing, the  advantage  is  liable  to  lie  with  the  apparently  weaker  indi- 
viduals unless  the  inferiority  be  due  to  actual  disease.  In  them  the 
technical  part  of  the  operation  is  usually  easier,  they  seem  to  be 
better  able  to  handle  infection  when  it  is  present,  and,  as  a  rule, 
they  are  less  liable  to  postoperative  pneumonia  and  similar  compli- 
cations. 

The  great  danger  with  the  constitutionally  weaker  class  of  indi- 
viduals lies  not  so  much  in  the  mortality  as  in  the  temptation  con- 
stantly presented  to  the  surgeon  to  try  and  accomplish  the  impossible 
in  the  way  of  making  well  and  strong  those  who  are  fundamentally 
defectives.  As  W.  J.  Mayo  has  recently  emphasized,  the  surgeon 
must  not  expect  to  make  the  man  who  is  thin  and  sLx  feet  high  into 
one  who  is  fat  and  five  feet  six  inches  high  by  any  operative  procedure. 
Yet,  if  we  study  the  history  of  surgery,  especially  during  the  past  two 
decades,  we  cannot  help  but  be  impressed  with  the  fact  that  many 
surgeons  have  been,  and  for  that  matter  still  are,  actively  engaged 
in  trying  to  make  over  the  thin,  nervous,  droop-bellied,   visceral- 


THE  PROGNOSIS  OF  ALL  SURGICAL  DISEASES  29 

sensitive  woman  into  a  strong  normally  innervated  individual,  usually 
by  taking  a  tuck  or  two  in  the  auxiliary  supports  of  whatever  organ 
may  strike  the  fancy  of  the  operator.  The  wise  surgeon,  who  values 
his  end-results  and  his  lasting  reputation  as  much  as  his  mortality- 
rate  and  record  'Of  operations  performed,  places  a  very  high  value 
on  the  factor  of  "constitution"  in  so  far  as  it  may  effect  the  final 
results  of  his  work. 

Neurotic  Temperament. — ^The  question  of  the  nervous  weakling  has 
for  years  been  one  of  great  practical  importance  in  surgery.  The 
many  terms  which  have  been  used  to  describe  this  class  of  patients 
illustrates  the  confusion  which  exists  regarding  them,  and  yet  in 
general,  the  neurotic  individual  is  not  difficult  to  recognize.  Most 
of  them  are  physically  below  the  average,  and  yet  comparatively 
few  actually  show  well-marked  evidences  of  disease.  Their  com- 
plaints are  always  out  of  proportion  to  the  objective  evidences  of 
gross  pathology. 

Many  of  these  neurotic  patients  seem  to  be  endowed  with  an 
abnormal  visceral  sense  which  makes  them  subjectively  conscious  of 
the  workings,  of  their  internal  organs  and  these  visceral  sensations 
come  to  occupy  a  large  sphere  in  their  mental  processes.  It  is  these 
visceral  hypersensitives  who  make  up  a  large  proportion  of  the  doubt- 
ful cases  which  the  surgeon  is  called  upon  to  diagnosticate  and  treat. 
Others  are  acutely  sensitive  beyond  normal  limits  to  all  sorts  of 
painful  stimuli,  and  still  others,  the  true  neurasthenics,  appear  to  be 
simply  in  a  state  of  chronic  nervous  exhaustion.  All  of  these  types 
are  continually  seeking  cure  by  surgical  means,  and  operations  devised 
for  the  purpose  of  curing  them  are  continually  being  described. 

In  studying  the  history  of  surgical  attempts  to  cure  these  cases 
we  find  surgeons  at  one  time  directing  their  efforts  against  the  ovaries, 
while  at  another  period  uterine  antiflexion  was  supposed  to  be  the 
really  important  factor,  and  at  still  another  period  movable  kidneys 
were  looked  upon  as  the  most  important  cause  of  trouble— to  say 
nothing  of  the  chronic  appendix.  Recently  tucking  up  the  intestines 
was  in  great  favor  with  a  few  operators,  while  others  turned  to 
resections  of  the  colon.  These  periods  of  operative  experimenta- 
tion are  mentioned  because  the  fact  should  not  be  lost  sight  of  that 
the  surgeons  were  in  each  period  dealing  with  essentially  the  same 
class  of  patients,  and  at  no  time  have  any  considerable  proportion  of 
these  patients  been  permanently  benefited  by  surgery.  The  prog- 
nosis as  regards  mortality  in  these  patients  is  usually  excellent,  but 
as  regards  cure  from  the  viewpoint  of  the  patient  and  the  patient's 
relatives  and  friends  these  operations  have  been  almost  uniformly 
failures. 

Surgically  the  nervous  weakling  should  receive  the  same  considera- 
tion as  any  other  patient,  no  less  and  no  more.  Above  all,  real  physi- 
cal findings  of  disease  should  be  the  basis  for  operation  and  not  the 
patient's  account  of  his  or  her  subjective  sensations.  It  is  seldom 
necessary  to  operate  for  pain  alone.    The  subjective  pain  of  the 


30  SURGICAL  PROGNOSIS 

patient  nmst  be  substantiated  by  some  objective  finding  of  the  surgeon. 
Yet  frequently  we  find  surgeons  operating  for  pain  which  they  do  not 
know  to  exist. 

SPECIAL   CONDITIONS    AFFECTING    SURGICAL   PROGNOSIS. 

Obesity. — Overweights  are  poor  Hfe  insurance  risks  in  ahiiost  direct 
proportion  to  the  degree  of  excess  weight,  and  the  same  handicap 
appHes  to  these  patients  as  surgical  risks.  A  moderate  amount  of 
excess  fat,  as  a  rule,  has  little  effect  on  the  prognosis  other  than  to 
increase  the  technical  difficulties  of  the  operation.  With  greater 
degree  of  obesity  many  difficulties  and  even  dangers  begin  to  make 
themselves  manifest. 

Excessive  quantities  of  fat  not  only  increase  the  technical  difficulties 
of  the  operation,  but  the  very  presence  of  the  fat  in  excessive  quan- 
tities renders  these  patients  bad  subjects  for  either  general  or  local 
anesthesia.  The  respiration  is  usually  interfered  with,  and  they  take 
the  anesthetic  badly  causing  cyanosis,  venous  stasis  and  increased 
hemorrhage.  Later  these  patients  are  particularly  prone  to  develop 
postoperative  pulmonary  complications.  Acute  cardiac  dilatation  is 
a  complication  which  may  be  encountered,  especially  if  the  patient 
be  kept  for  any  length  of  time  in  the  Trendelenburg  position.  Fat 
embolism  is  another  complication  which  probably  occurs  more  fre- 
quently than  is  generaly  recognized. 

Fat  is  essentially  a  tissue  of  low  vitality.  Adipose  tissue  and 
obese  individuals  in  general  are  notoriously  little  resistant  to  infection. 
Experimental  observations  have  shown  fat  to  be  the  least  resistant 
tissue  in  the  body  to  infection,  and  this  has  been  abundantly  confirmed 
clinically.  It  is  likewise  a  particularly  slow-healing  tissue,  the  fat 
itself  acting  much  as  a  benign  foreign  body  while  the  repair  proceeds 
chiefly  from  the  interlobular  connective-tissue  septa.  Whereas  the 
serum  exuded  between  two  cut  surfaces  is  an  essential  element  in  the 
healing  process,  oil  pressed  out  from  the  fat  and  collecting  between 
cut  surfaces  must  first  be  removed  before  repair  can  proceed. 

Ventral  hernias  and  similar  postoperative  partial  failures  are  more 
common  after  operations  on  the  obese.  This  is  due  largely  to 
the  fact  that  the  incision  is  called  upon  to  support  excessive  strains 
incident  to  the  increased  weight  while  at  the  same  time  the  tissues 
used  in  closing  the  wound  are  often  so  infiltrated  with  fat  that  they 
are  soft  and  yielding.  Another  reason  is  that  surgeons  are  prone  to 
forget  the  slow  repair  in  these  patients.  Obese  patients  should  be  kept 
in  bed  after  laparotomies  until  adequate  time  has  elapsed  for  the  union 
of  the  slow-healing  tissues. 

Alcoholism. — The  chronic  alcoholic  is  a  peculiarly  unreliable  surgi- 
cal risk.  All  that  life  insurance  companies  say  concerning  the  dangers 
of  chronic  alcoholism  may  be  repeated  with  special  emphasis  as 
applying  to  the  effect  of  alcoholism  on  operative  prognosis. 

These  patients  almost  uniformly  take  an  anesthetic  poorly,  and 


SPECIAL  CONDITIONS  AFFECTING  SURGICAL  PROGNOSIS       31 

they  are  also  notoriously  bad  subjects  when  it  comes  to  resisting  an 
infection  of  any  kind.  Postoperative  pneumonia  is  a  particularly 
dangerous  complication  for  them. 

The  liability  of  the  chronic  alcoholic  to  develop  delirium  tremens 
after  even  minor  accidents  or  operation  is  known  to  every  hospital 
attendant.  Particularly  is  this  so  after  fractures,  where  it  is  possible 
that  fat  emboli,  which  in  other  patients  would  produce  no  symptoms, 
may  play  a  part  in  the  etiology. 

The  worst  subject  is  usually  the  alcoholic  between  forty-five  and 
sixty  years  of  age.  By  this  time  many  of  the  chronic  alcoholics  have 
reached  a  condition  of  general  disintegration,  when  some  otherwise 
minor  disease  is  all  that  is  necessary  to  carry  them  off,  and  if  this 
trouble  happens  to  be  of  a  surgical  nature  they  are  very  likely  to  be 
added  to  the.  surgeon's  list  of  failures. 

The  alcoholic  who  survives  sixty  seems  often  to  be  made  of  tougher 
material  than  the  average  man,  so  that  among  old  men  alcoholism 
would  appear  to  have  less  effect  on  the  operative  prognosis  than  it 
does  among  the  middle-aged. 

Heart  Disease. — ^The  laity  and  many  general  practitioners  lay 
special  stress  on  the  dangers  of  general  anesthesia  in  the  presence 
of  valvular  heart  disease.  This  belief  is  probably  handed  down 
from  the  days  of  relatively  frequent  chloroform  fatalities.  Certainly 
experience  today,  with  ether  given  by  the  open  drop  method,  is  to 
the  effect  that  well-compensated  valvular  lesions  add  very  little  if  any 
risk  to  the  anesthetic.  Myocardial  degenerations  are,  on  the  other 
hand,  of  considerable  importance. 

Willius,^  in  a  recent  paper,  summarizes  the  experience  of  the  Mayo 
Clinic  as  to  the  operative  risk  in  cardiac  cases  as  follows : 

I.  The  decision  of  operability  in  cardiac  disease  depends  on  the 
factors  as  follows:  (1)  The  immediate  operative  risk,  (2)  the  probable 
improvement  of  the  heart  after  operation,  (3)  the  patient's  relative 
chance  for  length  of  life  or  general  health  with  and  without  operation, 
and  (4)  in  less  serious  conditions,  whether  the  operative  relief  will 
justify  the  added  risk, 

II.  Cases  in  which  the  heart  permits  the  patient  to  go  about  in  rela- 
tive comfort,  or  in  which  it  can  be  sufficiently  restored  by  treatment  to 
allow  this,  usually  are  considered  safe  for  operation. 

III.  Malignancy  complicated  by  heart  disease  is  usually  considered 
operable  if  a  fair  hope  of  cure  is  offered. 

IV.  The  best  measure  of  operative  risk  is  a  good  clinical  impression 
of  the  patients'  ability  to  stand  physical  strain,  supplemented  by  a 
careful  history  and  a  thorough  physical  examination. 

V.  Preoperative  medical  therapy  and  rest  combined  with  surgical 
and  medical  correlation  after  operation,  is  of  paramount  importance. 

VI.  The  general  tendency  is  to  require  too  great  a  margin  of  cardiac 
safety  in  surgical  w^ork. 

1  The  Operative  Risk  in  Cardiac  Disease,  American  Journal  of  Surgery,  Oct..  1918. 


32  SURGICAL  PROGNOSIS 

Renal  Disease. — The  relationship  of  renal  disease  to  surgical  prog- 
nosis is  one  which  must  be  approached  with  great  caution.  Albumin 
and  casts  are  such  frequent  accompaniments  of  so  many  conditions 
requiring  surgical  treatment  that  they  in  themselves  have  little 
influence  on  the  prognosis.  On  the  other  hand  grave  renal  disease 
may  be  an  almost  absolute  contra-indication  to  operation.  In  general, 
it  may  be  said  that  the  dangers  depend  upon  the  evidences  of  renal 
insufficiency  rather  than  upon  the  results  of  the  urine  examination. 
Elective  operations  in  the  presence  of  demonstrable  renal  insufficiency 
should,  as  a  rule,  be  approached  with  great  caution  or  abandoned 
entirely,  but  if  the  condition  of  the  patient  be  such  as  to  actually 
demand  operative  interference  the  renal  lesion  may  usually  be  dis- 
counted as  a  contra-indication  to  operation.  The  dangers  of  operating 
in  the  presence  of  uremia  or  on  parts  edematous  with  chronic  renal 
disease  cannot,  of  course,  be  overestimated. 

The  relation  of  renal  disease  to  the  surgery  of  the  urinary  tract 
wall  be  discussed  under  the  chapter  dealing  with  this  subject. 

High  Blood-pressure. — High  blood-pressure  is  a  symptom  which 
should  be  given  due  weight  in  so  far  as  it  indicates  grave  cardiovascular 
or  renal  disease. 

Low  Blood-pressure. — A  markedly  low  blood-pressure  is  always  a 
dangerous  prognostic  sign  in  surgical  cases.  During  and  following 
operations  it  is  a  symptom  of  shock.  Previous  to  an  operation  it 
may  signify  shock  or  hemorrhage  or  some  grave  asthenic  condition. 
Except  for  the  purpose  of  preventing  further  active  hemorrhage, 
operations  should  very  rarely  be  undertaken  if  the  systolic  blood- 
pressure  is  under  100  mm.  Hg.  A  blood-pressure  below  90  mm.  Hg 
is  almost  a  positive  contra-indication  to  active  operative  interference. 

Low  Pulse-pressure. — The  pulse-pressure  should  equal  approximately 
one-third  of  the  systolic  pressure.  In  shock,  grave  hemorrhage  and  a 
number  of  other  conditions  affecting  seriously  the  prognosis,  the  pulse 
pressure  is  found  to  be  low  in  relation  to  the  systolic.  Patients  having 
a  pulse  pressure  of  less  than  one-third  of  the  systolic  pressure  should 
always  be  viewed  with  suspicion,  A  sudden  fall  in  pulse-pressure  during 
the  course  of  a  disease  or  following  an  operation  is  a  grave  prognostic 
sign. 

Diabetes. — Diabetics  are  notoriously  bad  surgical  risks.  Wound  in- 
fection, non-healing  and  diabetic  coma  are  the  three  dangers  peculiar 
to  operations  on  diabetic  patients.  Of  these  coma  is  by  far  the  most 
frequent  and  the  most  difficult  to  prevent.  Karewski  reports  136 
operations  on  diabetics  with  a  mortality  of  20  per  cent,  and  of  these 
78  per  cent,  died  in  coma. 

Sepsis  and  non-healing  can  be  very  largely  controlled  by  the  use  of  a 
rigid  aseptic  technic  and  great  care  to  avoid  unnecessary  trauma  to  the 
tissues. 

For  many  years  surgeons  generally  have  held  to  the  belief  that 
if  the  diabetic  patient  could  be  rendered  sugar-free,  an  operation 
could  then  be  performed  with  relative  safety,  "This  idea  was  based 


SPECIAL  CONDITIONS  AFFECTING  SURGICAL  PROGNOSIS    33 

largely  on  the  work  of  Phillips^  who  in  1902  reported  a  large  series  of 
cases  from  the  literature  showing  a  mortality  of  36.37  percent,  in  cases 
not  subjected  to  preoperative  treatment  and  17.7  per  cent,  in  treated 
cases.  More  recently  it  has  been  showQ  that  the  well-kno"UTi  dangers 
accompanying  attempts  to  render  the  urine  sugar-free  in  medical 
practice  hold  with  equal  force  in  surgical  work  and  that  preoperative 
dietary  treatment  unless  it  is  surrounded  with  all  the  safeguards  knoT^m 
to  the  medical  treatment  of  this  disease  is  likely  to  actually  increase 
the  dangers  of  coma. 

The  dangers  of  operating  in  the  presence  of  diabetes  can  scarcely 
be  overestimated  and  yet  under  certain  conditions  the  diabetic  seems 
to  offer  but  a  moderately  increased  operative  risk.  Fifty  per  cent,  of 
the  postoperative  coma  cases  reported  by  Karewski  were  in  so-called 
mild  diabetics  and  it  may  be  said  that  the  factors  governing  the  selec- 
tion of  safe  operative  risks  in  the  presence  of  this  condition  are  not  yet 
fully  understood.  In  general  it  may  be  said  that  no  diabetic  should 
be  operated,  except  in  the  gravest  emergency  without  first  demon- 
strating the  patient's  ability  to  maintain  a  sugar-free  urine  without 
developing  any  of  the  well  known  acidosis  complications  of  the  disease. 

Acidosis. — ^This  term  has  been  used  to  designate  conditions  varying 
in  importance  from  the  slight  increase  in  the  H-ion  concentration  of  the 
blood  which  follows  severe  exercise  to  the  grave  acid  intoxications  of 
the  tj'pe  encountered  in  diabetic  coma.  Theoretically  acidosis  explains 
certain  phases  of  the  abnormal  physiology  encountered  in  many  serious 
conditions.  As  a  rule  the  underlying  causes  of  the  acidosis  are  readily 
recognizable  and  when  acidosis  is  demonstrable  in  the  presence  of  these 
causes  the  prognosis  is  serious  and  when  possible  the  operation  should 
be  postponed  until  the  acidosis  can  be  remedied.  Occasionally  the 
surgeon  encounters  patients  suffermg  from  a  grave  acidosis  without 
the  underlying  disease  being  apparent. 

Russ^  states  that  the  warning  signs  in  such  cases  are: 

1.  A  history  of  unaccountable  headaches,  vertigo,  attacks  of 
dyspnea,  occasional  nausea  or  vomiting,  an  unreasonable  dread  of 
the  operation,  tachycardia  and  other  nervous  sjTuptoms. 

2.  A  peculiar  sweetish  odor  to  the  breath,  suggesting  the  odor  of 
rotten  apples.     In  some  cases  this  is  marked  and  unmistakable. 

3.  The  presence  in  the  urine  of  the  acetone  bodies. 

He  further  says  that  to  disregard  these  warning  signs  is  to  subject 
the  patient  at  best  to  (1)  an  anesthesia  requiring  large  amounts  of 
ether  or  chloroform  and  attended  with  struggling  and  great  rigidity 
of  the  muscles,  difficult  breathing,  a  rapid  pulse  and  nausea  and 
followed  by  a  prolonged  and  nerve-racking  convalescence,  with  per- 
sistent vomiting,  restlessness,  dyspnea,  a  rise  in  temperature  and 
much  suffering;  or,  if  less  fortunate,  to  (2)  the  certainty  of  a  fatal 
termination,  preceded  by  nausea,  air-hunger,  persistent  vomiting,  a 

'  Surgical  Aspects  of  Glycosuria  and  Diabetes,  Lancet,  1902,  i,  1308-1386. 
2  Acidosis  as  a  Complication  after  Surgical  Operations,  Jour.  Am,  Med.  Assn.,  1913, 
Ixxxi,  1618. 

3 


34  SURGICAL  PROGNOSIS 

rise  in  temperature,  great  nervousness  and  followed  by  cama  and 
death  in  from  ten  hours  to  two  or  three  days. 

The  writer^  has  had  one  postoperative  death  due  to  this  cause, 
and  can  recall  three  other  deaths  which  were  probably  due  to  this 
condition.  As  a  complication  in  surgical  work  acidosis  is  undoubtedly 
rare  and  the  data  so  far  available  concerning  it  is  by  no  means  conclu- 
sive, and  yet  as  surgeons  learn  to  eliminate  the  more  common  causes  of 
failure  these  rare  conditions  assume  greater  relative  importance. 

Intestinal  Auto-intoxication. — Few  subjects  in  medicine  or  surgery 
have  been  mere  written  about  with  less  clear  understanding  than 
has  the  question  of  auto-intoxication  of  intestinal  origin.  Some  even 
claim  that  the  victims  of  this  condition  are  bad  general  surgical  risks 
prone  to  all  sorts  of  complications.  It  would  seem,  however,  that  in 
all  but  the  most  severe  grades  of  the  condition  its  effect  on  the  imme- 
diate operative  prognosis  is  of  but  very  slight  importance. 

It  is  in  connection  with  the  question  of  the  ultimate  prognosis  of 
operations  performed  for  other  conditions  and  those  directed  toward 
th3  relief  of  this  condition  that  the  subject  of  intestinal  auto-intoxica- 
tion assiunes  great  practical  importance.  That  the  surgical  end-results 
in  cases  operated  for  the  various  phases  of  so-called  auto-intoxication 
have  up  to  the  present  time  been  often  unsatisfactory  is  generally 
accepted.  Fiu-thermore,  it  seems  highly  probable  that  the  results 
will  remain  unsatisfactory-  until  some  really  definite  knowledge  is 
obtained  concerning  the  etiology  of  the  condition.  Up  to  the  present 
time  no  really  definite  proof  of  the  actual  existence  of  intestinal 
auto-intoxication  as  a  clinical  entity  has  ever  been  demonstrated.  Is 
the  constipation  which  is  usually  present  the  cause  of  the  diseased 
condition  or  is  the  primary  disease  or  defect,  whatever  it  may  be,  the 
cause  of  the  intestinal  derangement?  In  spite  of  much  literature  on 
the  subject  this  question  has  not  yet  been  answered. 

Hemophilia. — This  rare  condition  may  lead  to  serious  or  even  fatal 
hemorrhage  after  operation  which  imder  other  circumstances  would 
be  considered  most  minor  surgical  procedures.  ^Yithin  recent  years 
excellent  results  have  been  reported  from  the  use  of  alien  or  human 
sermn  injections  or  better  the  transfusion  of  whole  blood  given  with 
the  idea  of  adding  to  the  blood  of  the  hemophiliac  those  substances 
essential  for  thrombus  formation  which  are  ordinarily  lacking  in  the 
blood  of  these  patients. 

In  this  connection  it  might  be  well  to  emphasize  a  point  concerning  the 
use  of  serums  or  blood  in  general  to  control  the  hemorrhagic  tendencies 
associated  with  this  and  other  conditions,  and  that  is  that  thrombus 
formation  and  even  ordinary  coagulation  are  vers'  complex  processes. 
Recent  investigations  have  sho-^n  that  they  are  really  resultants  of  the 
action  of  many  substances,  and  that  because  borrowed  serum  supplies 
the  missing  link  in  one  case  is  no  reason  why  it  should  be  expected  to 
give  equal  results  in  other  cases  of  diverse  origin.     The  outcome  in 

'Analysis  of  Deaths  in  1573  Surgical  Operations,  Albanv  Med.  Ann.,  August,  1914, 
p.  432. 


SPECIAL  CONDITIONS  AFFECTING  SURGICAL  PROGNOSIS       35 

one  case  may  be  excellent  and  in  another  altogether  disappointing, 
depending  upon  factors,  as  yet  none  too  well  understood,  and  requiring 
careful  study  in  each  individual  case  before  any  operative  procedure 
should  be  undertaken. 

Jaundice. — Jaundice  in  itself  indicates  the  presence  of  a  serious 
pathological  condition  so  that,  irrespective  of  the  special  dangers 
incident  to  the  jaimdice  per  se,  the  prognosis  in  the  presence  of  jaundice 
should  always  be  guarded.  Aside  from  the  dangers  incident  to  those 
pathological  conditions  which  may  be  primarily  responsible  for  the 
jaundice,  there  are  two  additional  special  dangers  which  must  always 
be  reckoned  with  when  operating  on  these  patients.  The  first  is 
referable  to  the  liver  itself  and  is  probably  the  result  of  an  interference 
with  the  liver  function  due  to  a  sudden  relief  of  pressure  in  the  biliary 
ducts.  The  phenomenon  is  undoubtedly  similar  in  kind  to  the  renal 
failure  frequently  noted  after  suddenly  relieving  the  urinary  pressure 
in  long-standing  cases  of  urinary  obstruction.  The  danger  of  this 
grave  complication  is  always  present  when  operating  on  the  biliary 
tract  in  the  presence  of  obstructive  jaundice.  A  fatal  postoperative 
termination,  the  direct  result  of  hepatic  failure,  is  an  almost  invariable 
rule  in  cases  in  which  the  obstruction  has  persisted  until  only  a  clear 
watery  fluid  is  found  in  the  bile  ducts  at  operation. 

The  second  danger  associated  directly  with  jaundice  is  hemorrhage. 
Operations  performed  in  the  presence  of  jaundice  are,  under  certain 
circumstances,  liable  to  be  followed  by  prolonged  oozing  from  vessels 
which  under  ordinary  conditions  would  scarcely  bleed  at  all.  Jaundice 
is  not  always  associated  with  this  tendency  to  hemorrhage.  The 
majority  of  jaundiced  patients  coming  to  operation  are  not  noticeably 
bad  bleeders,  and  yet  in  these  patients  the  possibility  of  this  dangerous 
condition  must  always  be  borne  in  mind. 

The  causes  of  the  hemorrhagic  condition  associated  with  jaundice 
are  not  well  understood.  In  general  it  bears  a  relation  to  the  dura- 
tion and  intensity  of  the  jaundice  but  this  relationship  is  not  fixed 
and  there  may  be  wide  fluctuations  in  the  hemorrhagic  tendency  in 
individual  cases  without  known  cause.  These  patients  frequently 
bleed  to  death  from  simple  trocar  punctures.  In  deeply  jaundiced 
patients  with  evidences  of  purpura  the  danger  of  hemorrhage  has 
usually  been  considered,  along  with  the  other  dangers  associated 
with  this  condition,  almost  an  absolute  contra-indication  to  operation. 
In  these  cases  the  operative  mortality  is  so  high  as  to  be  prohibitive 
while  under  conservative  treatment  a  fair  proportion  ultimately  clear 
up  provided  the  obstruction  be  not  due  to  malignant  disease. 

Within  recent  years  ]\Iunro,^  Moynihan^  and  others  have  claimed 
good  results  in  the  way  of  controlling  the  hemorrhage  by  the  injection 
of  alien  serum  before  and  after  the  operation,  and  equally  good  results 
have  been  claimed  from  the  similar  use  of  blood  or  serum  obtained 
from  normal  individuals.     The  factors  governing  success  or  failure 

1  Boston  Med.  and  Surg.  Jour.,  March  25,  1909. 

2  British  Med.  Jour.,  October  2,  1909. 


36  SURGICAL  PROGNOSIS 

are  not  thoroughly  understood  and  frequent  failures  are  reported 
alongside  of  the  successes. 

The  writer^  has  had  one  death  from  anaphylactic  shock  following 
the  use  of  rabbit's  serum  in  a  case  of  jaundice. 

Anemia. — If  we  exclude  from  consideration  at  this  time  the  acute 
anemias,  the  result  of  sudden  hemorrhage,  it  may  be  said  that  the 
effect  of  anemia  per  se  on  the  operative  prognosis  is  in  almost  direct 
proportion  to  the  grade  of  the  anemia.  The  lesser  grades  of  anemia 
have  little  direct  effect  on  the  prognosis  other  than  to  indicate  the 
possibility  of  a  more  prolonged  postoperative  convalescence.  The 
more  severe  grades  of  anemia  affect  the  prognosis  in  two  ways:  In  the 
first  place  the  presence  of  a  well-marked  anemia  is  usually  of  itself  an 
indication  of  the  presence  of  some  serious  disease  capable  of  causing 
the  anemia.  In  the  second  place  the  more  severe  grades  of  anemia 
considerable  increase  the  dangers  accompanying  any  operative  pro- 
cedm*e.  IMikulicz  believed  that  no  operative  work  requiring  a  general 
anesthesia  should  be  undertaken  in  a  patient  with  less  than  30  per 
cent,  of  hemoglobin.  Certainly  no  operation  should  be  undertaken 
in  the  presence  of  extreme  anemia  unless  the  patient  is  suffering  from 
some  form  of  continuing  hemorrhage  not  controllable  by  non-operative 
means.  In  most  cases  of  severe  anemia  it  is  better  to  keep  the  patient 
under  conservative  treatment  until  the  condition  of  the  blood  can  be 
improved  to  such  an  extent  as  to  make  the  operation  safe.  In  all  cases 
of  severe  anemia  the  possible  use  of  blood  transfusions  should  always 
be  kept  in  mind. 

This  does  not,  however,  mean  that  a  patient  who  is  already  a 
reasonably  good  operative  risk  should  be  kept  for  a  long  time  under 
conservative  treatment  subject  to  the  dangers  of  the  disease  itself 
if  a  more  rapid  improvement  could  be  confidently  predicted  after 
operation.  As  a  rule,  if  the  hemoglobin  is  over  50  per  cent,  the  special 
dangers  due  to  the  anemia  are  not  such  as  to  warrant  prolonged 
delay  unless  there  is  little  danger  in  delaying  the  operation  and  the 
general  condition  of  the  patient  is  improving  at  least  approximately 
as  rapidly  as  could  be  expected  after  operation. 

Acute  Bronchitis. — In  the  writer's  experience  ether  given  to  patients 
suffering  from  acute  bronchitis  has  almost  invariably  resulted  in  an 
exacerbation  of  the  pulmonary  trouble.  This  exacerbation  is  always 
distressing  to  the  patient,  if  not  actually  dangerous,  and  should  be 
avoided  if  possible  by  postponing  the  operation  until  such  time  as 
the  patient  has  recovered  from  his  bronchitis.  If  the  patient  wath 
acute  bronchial  trouble  must  be  operated  some  form  of  anesthesia  other 
than  inhalation  ether  anesthesia  should  be  selected  if  possible.  Local 
novocain  or  spinal  anesthesia  are  the  methods  usually  selected. 

In  contrast  to  acute  bronchial  infection  the  more  chronic  pulmonary 
troubles,  even  those  associated  with  empyema  and  pulmanary  abscess, 
are  often  but  little  influenced  by  the  anesthetic. 

1  An  Analysis  of  Deaths  in  1573  Surgical  Operations,  Albany  Med.  Ann.,  August, 
1914,  p.  442.' 


PROGNOSIS  OF  THE  OPERATION  ITSELF  37 

Surgeons  differ  in  their  opinions  concerning  the  dangers  of  operat- 
ing io  the  presence  of  pulmonary  tuberculosis.  It  is  certain,  however, 
that  a  general  anesthetic  never  does  the  condition  any  good,  and  that 
following  operations  exacerbations  of  the  pulmonary  lesions  are 
frequently  noted  due  either  to  the  anesthetic  or  to  a  postoperative 
period  of  lowered  immunity  against  the  disease. 

THE   PROGNOSIS    OF    THE    OPERATION   ITSELF. 

Accidents  and  Complications  Associated  with  Surgical  Operations. — 
Every  surgical  operation  has  associated  with  it  a  certain  element  of 
risk,  (1)  as  regards  tha  life  of  the  patient,  and  (2)  as  regards  the  danger 
of  unforeseen  complications  resulting  in  a  more  or  less  serious  disability 
directly  traceable  to  the  operation.  The  danger  may  be  so  slight  as 
to  be  almost  negligible,  nevertheless,  it  is  the  duty  of  the  surgeon  in 
each  individual  case  to  carefully  estimate  the  risks  involved  before 
undertaking  any  operative  procedure  no  matter  how  simple  or  how 
extensive  it  may  be.  This  is  necessary  not  only  that  he  may  arrive 
at  a  correct  decision  for  or  against  the  operation,  but  because  the  more 
carefuHy  the  estimate  is  made  the  better  will  the  surgeon  be  prepared 
to  avoid  those  complications  which  are  liable  to  interfere  with  the 
results  of  the  operation. 

In  order  to  get  a  clear  imderstanding  of  the  factors  influencing  the 
prognosis  of  the  operation  itself  it  is  necessary  to  discuss  separately 
each  of  the  accidents  and  complications  which  may  interfere  with  the 
outcome  of  the  ooeration.  The  list  is  a  formidable  one,  and  unless 
the  reader  constantly  bears  in  mind  the  fact  that  he  who  is  forewarned 
is  forearmed,  it  is  difficult  not  to  OA^erestimate  the  combined  dangers 
associated  with  most  surgical  operations. 

Table  II  has  been  prepared  for  the  purpose  of  showing  the  mortality 
of  a  munber  of  typical  operative  procedures.  This  table  was  piuposely 
compiled  from  data  representing  the  work  of  surgeons  of  concededly 
more  than  average  ability  so  as  to  show  what  can  be  accomplished 
at  the  present  time.  Similar  compilations  from  the  reports  of  many 
of  the  smaller  hospitals  throughout  this  country  would  seem  to  show 
that  the  average  mortality  of  the  average  operator  is  at  least  two 
and  in  some  cases  three  times  that  sho^n  in  the  table. 

The  influence  of  the  disease  itself  on  the  operative  mortality  is  well 
illustrated  in  the  results  of  operations  for  hernia  and  appendicitis. 
Only  13  patients  died  following  5984  operations  for  non-strangdated 
hernia  or  1  in  460  patients  operated  upon,  while  among  694  patients 
operated  upon  for  strangulated  hernia  at  St.  Thomas'  Hospital 
(London)^  between  1900  and  1909  there  were  120  deaths  or  1  in  5.8. 
FoUowing  3584  operations  for  interval  and  chronic  appendicitis  in 
several  American  hospitals  there  were  only  5  deaths  or  1  death  in  717 
operations.     After  9440  operations  for  acute  appendicitis  reported  in 

1  Battle,  W.  H.:     Lancet,  October  12,  1912,  p.  999. 


eaths. 

Proportion. 

13 

1  ill 

460.0 

120 

1  ill 

5.8 

.5 

1  ill 

717.0 

087 

1  in 

13.6 

33 

1  in 

76.0 

73 

1  in 

25.6 

17 

1  in 

26.6 

197 

1  in 

25.6 

26 

1  in 

54 . 5 

9.5 

1  in 

15.2 

61 

1  in 

16.4 

14 

1  in 

50.0 

3 

1  in 

354.0 

6 

1  in 

315.0 

1 

1  in 

465.0 

31 

1  in 

7.6 

26 

1  in 

6.1 

38  SURGICAL  PROGNOSIS 

the  last  few  years  by  individual  operators  in  this  and  foreign  countries, 
there  were  ()S7  deaths  or  1  death  in  13.0  cases.  All  studies  of  the  mor- 
tality followiiio;  operations  for  acute  api  endicitis  show  that  the  great 
majority'  of  the  deaths  occur  in  cases  accompanied  by  peritonitis  at  the 
time    of    operation. 

TABLE   II. 

Character  of  operation.  Operation. 

Radical  operations  for  non-strangulated  hernia  5984 
Operations  for  strangulated  hernia  ....        694 

Laparotomies  for  chronic  appendicitis  .      .      .  3584 

Laparotomies  for  acute  appendicitis       .      .      .  9440 
Laparotomies  for  miscellaneous  gynecological 

affections 2497 

Abdominal  hysterectomies  for  myoma  .      .      .  1843 

Abdominal  myomectomies 453 

Laparotomies  for  gall-stone  disease  .  5051 

Operations    for    non-perforated    duodenal    or 

pyloric  ulcer 1417 

Suprapubic  prostatectomy 1442 

Perineal  prostatectomy 1000 

Operations  on  kidney  and  ureter      ....        705 

Radical  operations  for  carcinoma  of  the  breast  1063 

Thyroidectomy  for  simple  goiter       ....  1893 
Operations    for    tuberculous    cervical    lymph 

nodes 465 

Partial  gastrectomy  for  carcinoma   ....        234 
Partial  resection  large  intestines  for  carcinoma        1 59 

Anesthesia. — In  estimating  the  effect  of  the  anesthetic  on  the 
operative  prognosis  it  is  necessary  to  consider  both  the  immediate 
dangers  occurring  during  the  administration  of  the  anesthetic  and  the 
more  remote  effects  of  the  anesthetic  such  as  the  lowering  of  the  vital 
powers  of  resistance  against  infection,  the  relation  of  the  anesthetic  to 
postoperative  lung  complications,  and  the  effect  of  the  anesthetic  on 
such  organs  as  the  kidneys  and  liver. 

Although  carelessness  or  incompetency  in  the  administration  of  any 
anesthetic  makes  that  individual  anesthesia  dangerous,  it  has  been 
abundantly  proved  that  with  a  competent  anesthetist  the  immediate 
dangers  due  to  the  anesthetic  itself,  when  employing  one  of  the  stand- 
ard methods  of  local  or  general  anesthesia,  is  so  slight  as  to  constitute 
almost  a  negligible  factor  in  the  prognosis  of  the  individual  case. 
Table  III,  compiled  by  Dr.  James  T,  Gwathmey^  shows  the  relative 
proportion  of  fatalities  to  the  number  of  anesthesias  in  278,945  cases 
reported  from  American  sources. 

Ether. — In  more  than  half  of  the  anesthesias  reported  in  this  table 
ether  was  given  by  the  open  drop  method  with  a  mortality  of  one 
death  in  5623  cases.  This  figure  is  considerably  higher  than  that 
given  in  the  much  quoted  statistics  of  Hewett,  i.  e.,  1  death  in  16,302 
ether  anesthesias,  but  the  higher  death-rate  undoubtedly  is  much 
nearer  the  true  average  under  ordinary  conditions.  The  facts  are 
that  the  risk  is  not  definable  in  terms  of  statistics  but  rather  in  terms 
of  the  skill  and  care  of  the  anesthetist.     Ether  properly  administered 

'  Jour.  Am.  Med.  Assn.,  1912,  lix,  1846. 


PROGNOSIS  OF  THE  OPERATION  ITSELF 


39 


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40  SURGICAL  PROGNOSIS 

is  so  safe  that  series  of  15,000  or  even  20,000  consecutive  cases  without 
an  anesthetic  death  are  not  uncommon.  The  writer  has  never  wit- 
nessed an  ether  fatality  in  the  hands  of  a  competent  anesthetist,  and 
yet  I  have  personal  knowledge  of  7  ether  fatalities  in  the  hands  of 
students  or  inexperienced  internes  representing  a  mortality  of  about 
1  in  500  for  ether  anesthesias  given  by  incompetent  anesthetists. 

Chloroform. — The  figures  given  for  chloroform,  i.  e.,  1  death  in  2408 
anesthesias  agree  approximately  with  other  stacistics  from  general 
sources  although  chloroform  statistics  vary  greatly.  Lawrie^  reports 
30,000  chloroform  anesthesias  without  a  death.  In  some  British 
hospitals  the  death-rate  is  said  to  be  as  high  as  1  in  250  cases.  German 
statistics  give  1  in  2200.  U.  S.  Army  figures  give  4  deaths  in  3931 
operations.  Hewett  reports  214  deaths  in  676,767  administrations, 
or  1  in  3162. 

Nitrous  Oxide  and  Oxygen. — The  figures  given  for  nitrous  oxide  and 
oxygen,  ^.  e.,  not  any  deaths  in  8585  anesthesias  show  the  possibilities 
of  this  form  of  anesthesia,  which  is  undoubtedly  one  of  the  safest  of 
the  general  anesthetics  in  the  hands  of  the  experts,  and  at  the  same 
time  one  of  the  most  dangerous  when  used  by  the  novice.  The  attempt 
a  few  years  ago  to  make  general  use  of  this  form  of  anesthesia  certainly 
resulted  in  a  very  much  higher  death-rate  than  that  shown  by  the 
figures  here  quoted. 

Spinal  Anesthesia. — Babcock,'^  in  a  summary  of  the  subject  of  spinal 
anesthesia,  gives  the  following  conclusions  based  on  a  personal  experi- 
ence of  over  5000  cases: 

"In  our  personal  experience  ether  and  spinal  anesthesia  have  been 
about  equally  dangerous,  ether  from  exigencies  compelling  a  profound 
narcosis  or  an  imperfectly  trained  anesthetist;  spinal  anesthesia  from 
an  unwise  selection  of  patients  and  an  imperfect  knowledge  as  to 
the  physiological  action  of  the  drug.  With  careless  or  unskilled 
use,  spinal  anesthesia  is  doubtless  much  more  dangerous  than 
ether. 

"The  morbidity  of  spinal  anesthesia  as  expressed  by  nausea,  vomit- 
ing, headache,  backache,  postoperative  pain,  and  albuminuria  is  less 
than  that  from  ether. 

"Ocular  palsy  may  result  from  spinal  anesthesia  where  contaminated 
or  deteriorated  solutions  are  used.  A  lateral  deviation  of  the  needle 
with  injury  to  a  nerve  root  may  be  followed  by  severe  neuritis  and 
secondary  palsy. 

"Secondary  degeneration  of  the  spinal  cord  from  the  chemical 
action  of  stovain,  properly  introduced  within  the  arachnoid  in  human 
beings,  for  purposes  of  spmal  anesthesia  is  doubted. 

"Functional  or  neurotic  symptoms  occur  after  spinal  anesthesia  as 
they  do  after  etherization,  and  may,  to  the  annoyance  of  the  surgeon, 
be  attributed  by  the  patient  to  the  injection. 

1  Bull.  Johns  Hopkins  Hosp.,  January,  1895. 

2  The  Dangers  and  Disadvantages  of  Spinal  Anesthesia,  New  York  Med.   Jour., 
November  8,  1913. 


.  PROGNOSIS  OF  THE  OPERATION  ITSELF  41 

"  If  a  steel  needle  be  used  it  may  be  broken  under  the  skin  during 
the  injection. 

"Danger  symptoms  may  follow  if  the  patient  be  moved  immediately 
after  the  injection  or  if  the  proper  posture  to  prevent  the  anesthetic 
from  reaching  the  upper  nerve  roots  be  not  maintained  for  at  least  one 
half  hour  after  the  injection. 

"Repeated  intradural  injections  seem  to  be  harmless. 

"Spinal  anesthesia  is  dangerous  in  circulatory  subtension,  conditions 
greatly  depressing  the  respiratory  centers,  shock,  collapse,  advanced 
myocardial  disease,  and  large  intrathoracic  effusions.  It  is  more 
dangerous  for  operations  upon  the  upper  abdomen  than  those  upon 
the  lower.  It  does  not  obviate  the  danger  of  sudden  cardiac  arrest 
in  operations  for  large  uterine  fibroids." 

The  experience  of  Babcock  and  a  number  of  other  surgeons  who 
have  had  extensive  experience  with  this  form  of  anesthesia  has  proved 
that  in  expert  hands  its  dangers  are  very  slight.  Equally  good  results 
have  not,  however,  been  obtained  by  surgeons  who  have  attempted  to 
make  occasional  use  of  spinal  anesthesia. 

The  Remote  EfEects  of  Anesthetics. — ^With  the  gradual  elimination  of 
the  more  immediate  dangers  associated  with  anesthesia  surgeons 
have  begun  to  pay  more  attention  to  the  influence  of  the  anesthetic 
on  the  postoperative  morbidity  and  mortality,  especially  as  regards 
its  influence  on  the  kidneys,  liver,  lungs  and  the  central  nervous 
system,  and  also  as  regards  its  effect  on  the  yital  forces  concerned  in 
the  resistance  against  infections. 

Effect  of  Anesthetics  on  the  Kidneys. — At  least  one-third  of  all  ether 
anesthesias  are  followed  by  albumin  and  casts  in  the  urine,  persisting, 
as  a  rule,  for  several  days.  Animal  experiments  have  shown  that 
ether  when  administered  in  sufficient  quantities  to  produce  general 
anesthesia  is  a  distinct  irritant  to  the  kidneys  in  approximately  direct 
proportion  to  the  amount  of  anesthetic  employed  and  the  duration  of 
the  anesthesia.  Clinical  experience  has,  however,  demonstrated  that 
in  the  great  majority  of  surgical  patients  the  slight  effect  of  the  ether 
on  the  kidneys  is  of  little  or  no  prognostic  significance. 

Chloroform  is  generally  understood  to  be  distinctly  less  irritating 
to  the  kidneys  than  ether. 

Nitrous  oxide  is  said  to  have  practically  no  effect  upon  the  kidneys. 
It  has,  however,  a  marked  effect  in  cases  suffering  from  arteriosclerosis. 

Cocain  and  its  derivatives  used  as  local  anesthetics  have  no  effect 
upon  the  kidneys. 

Cases  of  anuria  following  operations  other  than  those  on  the  urinary 
tract  are  very  rare,  and  it  is  now  known  that  many  cases  of  anuria 
following  operations  on  the  urinary  tract,  which  were  formerly  ascribed 
to  the  anesthetic,  were  in  fact  due  to  causes  entirely  apart  from  the 
anesthesia. 

The  Effect  of  Anesthetics  upon  the  Liver. — The  general  effect  of  the 
several  anesthetics  upon  the  liver  is  probably  not  essentially  different 
from  that  exerted  by  them  upon  the  kidneys.     In  most  cases  it  is  of 


42  SURGICAL  PROGNOSIS 

little  known  importance.  Within  recent  years  a  number  of  writers 
have  reported  cases  of  so-called  delayed  chloroform  poisoning  accom- 
panied by  very  serious  pathological  changes  in  the  liver  simulating 
those  found  in  acute  yellow  atrophy.  This  condition  is,  however,  so 
rare  as  to  have  practically  no  influence  on  the  prognosis  of  chloroform 
anesthesias. 

The  Effect  of  Anesthetics  upon  the  Lungs. — Postoperative  lung  com- 
plications are  among  the  most  frequent  and  serious  of  the  postoperative 
sequels,  yet  the  exact  role  played  by  the  anesthetic  in  these  cases  is  still 
open  to  question.  Attempts  to  show  any  well-marked  difference  in 
the  frequency  of  the  more  serious  pulmonary  complications  following 
the  use  of  different  forms  of  anesthesia  have  not  yielded  conclusive 
results. 

Ether  is  generally  conceded  to  be  the  most  irritating  of  the  general 
anesthetics,  and  the  minor  grades  of  bronchial  irritation  are  certainly 
relatively  more  frequent  after  ether  anesthesia. 

The  Effect  of  Anesthetics  upon  the  Nervous  System. — Notwithstanding 
the  fact  that  the  physiological  activities  of  certain  portions  of  the 
nervous  system  are  profoundly  altered  during  all  forms  of  anesthesia, 
actual  injury  to  the  nerve  cells  or  nerve  fibers  does  not  seem  to  occur 
under  ordinary  circmn stances.  In  fact  the  state  of  physiological  rest 
enforced  by  the  anesthesia  seems  to  protect  those  portions  of  the  ner- 
vous system  acted  upon  by  the  anesthetic  from  the  fatigue  changes  of 
overstimulation  which  would  otherwise  result  from  the  operative 
manipulations. 

The  Effect  of  Anesthetic  upon  Immunity  Factors. — This  is  one  of  the 
most  important  questions  related  to  anesthesia,  and  yet  it  is  one 
concerning  which  there  is  very  little  definite  data  available.  There 
is,  however,  abundant  clinical  evidence  to  show  that  a  prolonged 
ether  anesthesia  has  a  decidedly  deleterious  effect  on  those  complex 
immunity  factors  which  go  to  make  up  the  body's  power  to  resist 
infection.  The  effect  is  probably  similar  in  kind  to  that  observed  after 
an  alcoholic  debauch,  when  it  is  a  well-known  clinical  observation 
that  there  is  a  temporary  reduction  of  the  natural  immunity  against 
the  pyogenic  infections  as  well  as  gonorrhea,  typhoid  and  probably  all 
other  infections. 

There  is  practically  no  data  concerning  the  effect  of  chloroform  on 
immunity. 

Nitrous  oxide  and  the  local  anesthetics  are  said  not  to  appreciably 
lessen  the  natural  powers  of  resistance. 

Postoperative  Nausea  and  Vomiting. — The  siu-geon  is  liable  to  give 
scant  consideration  to  the  nausea  and  vomiting  which  so  frequently 
accompany  anesthesia,  and  yet  to  the  patient  it  is  usually  one  of  the 
most  distressing  features  of  the  operation  and  one  which  cannot  be 
entirely  ignored  in  considering  the  postoperative  prognosis.  \Yith 
ether  it  can  only  be  reduced  by  shortening,  as  much  as  possible  the 
duration  of  the  anesthesia,  and  by  giving  the  least  possible  amount  of 
the  anesthetic. 


PROGNOSIS  OF  THE  OPERATION  ITSELF  43 

While  it  is  imdoubtedly  true  that  chloroform  gives  rise  to  nausea 
and  vomiting  far  less  frequently  than  does  ether,  it  is  claimed  by  some 
that  when  these  sjonptoms  do  occur  following  chloroform  anesthesia 
they  are  of  a  much  severer  t^'pe.  After  nitrous  oxide  nausea  and 
vomiting  are  of  almost  negligible  importance. 

Hemorrhage. — Dieffenbach  has  said:  "From  the  behavior  of  a 
surgeon  in  cases  of  severe  hemorrhage  are  we  able  to  judge  of  what 
metal  he  is  made." 

The  intelligent  management  of  hemorrhage  demands  more  than  the 
mere  technical  ability  to  control  bleeding  vessels.  Ideal  surgery  would 
be  bloodless,  or  nearly  so,  yet  a  certain  and  sometimes  considerable 
loss  of  blood  is  the  price  which  must  be  paid  for  the  successful  comple- 
tion of  many  operations.  Along  with  the  technical  ability  to  control 
hemorrhage  it  is  most  important  that  the  siu-geon  be  able  to  estimate 
at  any  instant  the  balance  between  blood  assets  and  actual  or  probable 
blood  losses  in  the  patient  he  is  operating.  A  great  many  operations 
have  been  incompletely  performed  because  the  surgeon  became  fright- 
ened in  the  presence  of  an  amount  of  hemorrhage,  which  under  the 
circumstances,  was  of  little  relative  importance.  On  the  other  hand, 
many  patients  have  lost  their  lives  because  the  operator  failed  to  rea- 
lize the  immediate  importance  of  what  under  other  circumstances 
might  have  been  a" relatively  unimportant  loss  of  blood. 

The  amount  of  blood  which  can  be  lost  without  death  ensuing  has 
been  the  subject  of  extensive  observation  and  experimentation.  The 
total  quantity  of  blood  in  the  body  has  been  determined  as  amounting 
to  approximately  7.7  per  cent,  (one-thirteenth)  of  the  body  weight. 
That  is,  a  man  weighing  one  hundred  and  fifty  pounds  has  approxi- 
mately five  quarts  of  blood.  The  amomit  which  can  be  lost  depends 
upon  a  number  of  factors,  so  that  it  is  impossible  to  say  that  10  or  20 
or  40  per  cent,  can  bs  lost  without  death  ensuing. 

The  immediate  source  of  danger  from  hemorrhage  is  the  fall  of 
blood-pressure  to  a  point  at  which  the  circulation  cannot  be  main- 
tained. Up  to  a  certain  point  the  efi^ect  of  the  loss  of  blood  on  the 
blood-pressure  can  be  neutralized  by  a  general  contraction  of  the 
peripheral  vessels,  but  the  mechanism  by  which  this  adaptive  process 
is  carried  out  requires  an  appreciable  element  of  time  for  its  consum- 
mation. Sudden  hemorrhages  are,  therefore,  much  more  serious  in 
proportion  to  the  amount  of  blood  lost  than  are  slow  hemorrhages 
which  allow  time  for  the  adaptive  mechanism  to  keep  up  with  the  loss 
of  blood.  "The  effect  upon  the  blood-pressure  is  most  sudden  in 
venous  hemorrhage  from  the  large  venous  trunks  because  the  quantity 
of  blood  supplied  to  the  heart  is  more  immediately  reduced,  the  cardiac 
output  bemg  directly  proportional  to  the  venous  pressure.  The 
blood-pressiu-e  is  only  a  quarter  of  a  pound  to  the  square  inch  in  the 
veins,  whereas  m  the  arteries  it  amounts  to  four  pounds  to  the  square 
inch  or  from  ten  to  sixteen  times  that  in  the  veins." 

The  sudden  gush  of  blood,  even  though  it  be  controlled  before  the 
total  loss  has  reached  an  otherwise  considerable  amount  is  always 


44  SURGICAL  PROGNOSIS 

dangerous  because  of  the  collapse  which  is  liable  to  ensue.  On  the 
other  hand,  during  the  course  of  a  prolonged  operation  a  much  greater 
total  loss  of  blood  may  be  borne  by  the  patient  without  producing 
serious  symptoms. 

Individual  patients  midoubtedly  vary  greatly  as  regards  their 
ability  to  withstand  hemorrhage.  Women,  as  a  rule,  withstand 
hemorrhage  better  than  men,  and  hemorrhages  from  the  uterus  often 
seem  to  be  borne  better  than  equally  rapid  and  severe  hemorrhages 
from  other  sources.  Children  may  die  after  losing  relatively  small 
amounts  of  blood  and  old  people  are  particularly  susceptible,  probably 
because  theu"  sclerotic  vessels  do  not  aid  in  the  adaptive  contraction 
of  the  peripheral  vessels. 

The  best  guide  to  the  immediate  prognosis  in  cases  of  recent  hemor- 
rhage is  the  blood-pressure,  for  if  this  be  maintained  it  matters  little 
what  the  red  cell  count  or  the  hemoglobin  index  may  be. 

The  anemia  resulting  from  hemorrhage  is  usually  of  minor  impor- 
tance. The  loss  of  50  c.c.  which  is  a  fair  average  for  an  ordinary 
operation  is  immediately  replaced  out  of  the  reserve  fund  of  the  vascu- 
lar system  (Arneth).  In  surgical  conditions  it  is  very  seldom  that 
over  3  per  cent,  of  the  blood  is  lost  (Crile)  and  after  severe  hemorrhage 
the  regeneration  is  usually  complete  in  from  nineteen  to  twenty-four 
days  (Lyon).  Regeneration  is  said  to  be  most  rapid  in  adult  males 
(Matas).  Exhaustion  of  the  blood  regenerating  organs,  the  result  of 
long-continued  hemorrhages  previous  to  the  time  of  operation,  may 
greatly  retard  the  process  of  regeneration.  Likewise  the  presence 
of  any  systemic  disease  ordinarily  accompanied  by  anemia  will  retard 
the  regeneration  of  blood  lost  at  the  time  of  operation. 

Secondary  Hemorrhage. — ^The  elimination  of  sepsis,  the  selection  of 
more  suitable  ligature  materials,  and  a  better  understanding  of  ths 
principles  governing  the  ligation  of  vessels  has  very  largely  eliminated 
the  dangers  of  secondary  hemorrhage  in  most  fields  of  surgery.  There 
are  today,  however,  certain -operations  which  are  followed  by  secondary 
hemorrhages  with  sufficient  frequency  for  this  complication  to  have  a 
definite  influence  upon  the  prosrnosis  of  these  operations. 

Few  surgeons  of  experience  but  have  encountered  secondary  hemor- 
rhages following  amputation  of  the  cervix.  These  hemorrhages  are 
seldom  rapidly  fatal  and  can  be  readily  controlled  in  the  great  majority 
of  cases. 

Considering  the  large  number  of  tonsil  operations  performed, 
dangerous  secondary  hemorrhages  are  rare  and  when  they  do  occur 
they  can  usually  be  brought  under  control  without  great  difficulty. 

Hemorrhage  following  goiter  operations  is  nearly  always  due  to 
slipping  of  the  ligature  applied  to  the  superior  thyroid.  This  accident 
is  usually  caused  by  including  fibers  of  the  overlying  muscle  in  the 
ligature.  The  accident  is  very  serious  and  can  only  be  avoided  by 
faultless  primary  ligation  of  the  vessel. 

Secondary  hemorrhage  following  prostatectomy  is  relatively  fre- 
quent and  always  of  serious  import  owing  to  the  difficulty  of  controlling 


PROGNOSIS  OF  THE  OPERATION  ITSELF  45 

it  and  the  fact  that  prostatic  cases  are  usually  very  poor  subjects  for 
hemorrhage. 

Nephrotomy  is  not  infrequently  followed  by  secondary  hemorrhage 
which  may  be  rapidly  fatal.  It  is  always  difficult  to  control  and  often 
requires  secondary  nephrectomy. 

Hemorrhage  after  gastro-enterostomy  and  similar  operations  on  the 
gastro-intestinal  tract  constitutes  one  of  the  chief  dangers  in  this 
field  of  surgery.  These  can  only  be  avoided  by  most  careful  suturing. 
Crile  has  recommended  the  use  of  the  shoemakers'  stitch  in  intestinal 
work  because  of  the  control  it  gives  of  the  vessels  in  the  intestinal  wall. 

No  discussion  of  hemorrhage  is  complete  without  calling  attention  to 
the  results  obtained  by  direct  transfusion  in  the  treatment  of  these 
cases.  Many  cases  are  lost  that  might  be  saved  by  timely  transfusion. 
In  our  experience  the  citrate  method  has  been  entirely  satisfactory  and 
quite  as  easy  to  give  as  an  intravenous  injection  of  salvarsan.  When 
possible  the  donor  should  be  selected  according  to  approved  compat- 
ability  tests.  When  these  tests  have  not  been  possible  we  inject  very 
slowly  5  to  10  c.c.  of  the  citrated  blood  of  the  donor  into  the  recipient 
and  then  wait  five  or  six  minutes.  Symptoms  of  incompatability 
develop  very  promptly  and  are  readily  recognizable  so  that  if  no 
reaction  develops  in  five  or  six  minutes  it  is  usually  quite  safe  to  pro- 
ceed with  the  injection  of  the  maximum  quantity  of  blood. 

Shock. — "Shock  may  be  defined  to  be  a  depression  of  the  vital 
powers,  induced  suddenly  by  external  injury,  and  essentially  dependent 
upon  a  loss  of  innervation."     (S.  D.  Gross.) 

In  the  more  than  half  a  century  which  has  elapsed  since  the  publi- 
cation of  Gross's  System  of  Surgery  our  conception  of  shock  has  not 
materially  changed  or  have  we  greatly  increased  our  knowledge  of  the 
elemental  causes  of  shock.  "Shock  may  be  produced  by  a  great 
variety  of  causes,  some  of  a  bodily,  others  of  a  mental  character;  some 
external,  others  internal.  It  may  be  purely  nervous,  or  partly  nervous 
and  partly  hemorrhagic,  that  is,  dependent  upon  the  conjoined  loss 
of  nervous  and  sanguineous  fluids.  The  nature  and  extent  of  shock 
are  greatly  influenced  by  the  state  of  the  general  health  at  the  time 
of  the  accident,  the  amount  of  injury,  the  importance  of  the  part  more 
directly  assailed,  and,  also,  in  a  special  manner,  by  the  idiosyncrasy  of 
the  individual.  There  are  some  persons,  soldiers,  for  example,  of  the 
most  undoubted  courage,  men  who  would  not  hesitate  to  face  the 
mouth  of  the  cannon,  who  fall  into  a  state  of  the  most  profound  pros- 
tration from  the  most  trifling  accident;  who  turn  pale  and  tremble 
like  a  leaf;  whose  minds  are  perfectly  bewildered,  and  who  are,  as  it 
were,  completely  sttmned,  from  injuries  so  insignificant  as  not  to  affect, 
in  the  slightest  degree,  ordinary  persons.  Such  an  occurrence  can 
only  be  explained  by  a  reference  to  idiosyncrasy;  and  it  has  its  counter- 
part in  those  persons  who,  although  extremely  plethoric,  faint  from 
the  slightest  loss  of  blood,  or  even  from  the  mere  sight  of  that  fluid. 
There  are  other  persons,  on  the  contrary,  whom  hardly  any  accident, 
however  severs,  can  shock;  they  are  insensible  to  pain;  their  nervous 


46  SURGICAL  PROGNOSIS 

system  is  obtuse;  nothing  affects  them,  either  bodily  or  mentally;  a 
severe  blow  may  stmi  them,  but  the  effect  is  transient;  in  a  few  minutes 
they  are  completely  restored  to  consciousness  and  power.  Here, 
again,  is  an  example  of  idiosAiicrasy,  a  peculiarity  of  organization; 
in  the  former  case,  the  individual  is  all  nerve,  all  sensibility;  in  the 
latter,  all  blood,  all  muscle. 

"Mental  shock  is  often  extremely  severe,  and  is  occasionally  followed 
by  the  worst  consequences,  especially  when  it  occurs  during  the 
progress  of  a  severe  illness,  or  after  a  severe  surgical  operation.  Fright 
is  perhaps  the  worst  of  the  causes  of  mental  shock.  The  effect  of  terror, 
in  suddenly  exliausting  nervous  power,  is  well  illustrated  by  the  history 
of  those  persons,  who,  being  sentenced  to  be  bled  to  death,  actually 
died  on  hearing  water  trickling  into  the  basin,  which  they  supposed 
to  l)e  blood  issuing  from  their  veins,  after  the  arm  had  been  slightly 
pricked,  although  no  vessel  had  been  opened.  It  is  related  of  Dessault 
that  he  one  day  lost  a  patient,  about  to  be  lithotomized,  from  sheer 
fright.  The  man,  who  was  very  cowardly,  fainted  and  died  under 
the  impression  that  the  operation  was  progressing,  when  this  dis- 
tinguished surgeon  was,  in  fact,  only  tracing  with  his  nail  the  line  of 
the  intended  incision  on  the  perineiun. 

"Mental  and  corporeal  shock  are  often  combined;  and,  when  this 
is  the  case,  it  is  not  uncommon  to  see  the  former  predominate,  in  a 
very  marked  degree,  over  the  latter.  The  soldier  on  the  field  of 
battle  may  suffer  from  bodily  shock  induced  by  a  severe  wound;  he 
may  feel  that  he  is  badly  hurt,  but  still  he  is  sanguine  of  recovery,  and 
cheerfully  and  manfully  bears  up  under  his  affliction.  The  surgeon 
examines  his  wound  and  perceiving  its  grave  character,  informs  him 
that  it  will  probably  cost  him  his  life.  Instantly  the  case  assumes  a 
different  aspect;  the  system  is  ovenvhelmed  with  pertm-bation  and 
excitement;  the  vital  powers  are  depressed  to  the  utmost;  and  death 
takes  place  perhaps  several  days  sooner  than  it  would  otherwise  have 
done."     (Gross.) 

During  the  AYorld  War,  the  opportunities  for  obser\'ing  and  studying 
shock  were  almost  unlimited.  As  a  result  of  these  observations  we 
have  learned  to  differentiate  more  sharply  between  the  true  surgical 
shock  resulting  from  traumatism,  psychical  shock  and  hemorrhage. 
xA.t  present  it  would  seem  that  the  best  working  hypothesis  explaining 
the  phenomena  attending  shock  is  that  the  underlying  cause  of  shock 
is  due  to  a  diminution  in  the  normal  alkalinity  of  the  b'ood.  This 
hypothesis  gives  a  rational  basis  for  the  prevention  and  treatment  of 
shock  which  has  apparently  stood  the  tests  of  experience  as  encountered 
in  war  practice. 

In  accident  and  military  surgery  shock  is  still  encomitered  with 
much  the  same  frequency  as  in  the  time  of  Gross,  but  today  serious 
life-threatening  shock  has  been,  to  a  very  great  extent,  eliminated 
from  deliberately  planned  operative  siu"gery.  This  improvement  is 
due  to  a  better  understanding  of  the  mechanism  of  shock  and  how  to 
avoid  the  causes  responsible  for  its  production;  also,  to  the  fact  that 


PROGNOSIS  OF   THE  OPERATION  ITSELF  47 

surgeons  have  learned  what  may  and  what  may  not  be  done  under 
given  circiunstances  without  producing  dangerous  shock.  In  the 
writer's  experience  shock,  apart  from  hemorrhage,  has  been  responsible 
for  a  mortality  of  less  than  one-fifth  of  1  per  cent,  in  patients  subjected 
to  deliberate  operative  procediu-es,  and  not  over  2  per  cent,  of  major 
operative  cases  have  suffered  from  shock  of  a  degree  sufficient  to  cause 
the  least  anxiety  as  to  the  outcome.  In  order  to  get  the  best  results 
it  is  necessary  for  the  surgeon  not  only  to  know  the  usual  causes  of 
shock  and  how  to,  as  far  as  possible,  avoid  them,  but  he  should  in  each 
individual  case  in  which  shock  is  at  all  liable  to  be  an  important  factor 
make  a  careful  estimate  of  the  shock  risk  and  plan  every  detail  of 
the  operation  accordingly. 

Patients  differ  greatly  as  regards  susceptibility  to  shock,  the  special 
dangers  occiuring  largely  in  those  handicapped  by  readily  recogniz- 
able impairments  which  make  them  especially  susceptible  to  the 
action  of  shock-producing  causes.  Different  regions  and  organs  of  the 
body  also  show  different  degrees  of  susceptibility. 

Temperament. — Experimental  investigations  have  shown  that  noxious 
impulses  transmitted  through  the  nervous  system  are  the  immediate 
cause  of  shock  and  practical  experience  has  shown  that  the  high-strung, 
acutely  sensitive  individual  is  more  susceptible  to  shock  than  is  the 
phlegmatic  t\'pe  of  patient. 

Frightened  patients  are  particularly  bad  shock  risks,  and  most 
students  of  this  subject  believe  that  fright  itself  is  an  important 
element  in  the  production  of  shock. 

Previous  Nerve  Exhaustion. — ]\Iany  look  on  shock  as  essentially  a 
phase  of  nerve  exhaustion  and  certainly  patients  who  from  overwork 
or  worry  have  exhausted  their  reserve  of  nervous  energy  are  more 
susceptible  to  shock  than  is  the  man  or  woman  who  has  lived  a  rational 
life  keeping  each  bodily  function  up  to  a  normal  standard  of  activity. 
Crile  says  that  the  worst  risk  is  probably  the  overworked  surgeon, 
about  fifty  years  of  age.  Work  short  of  actual  exhaustion  is,  how- 
ever, not  a  handicap,  because  the  industrious  and  those  who  have 
by  their  daily  life  accustomed  themselves  to  overcoming  the  lesser 
trials  of  everj'-day  existence  are,  other  things  being  equal,  far  better 
shock  risks  than  are  the  idle  luxurious  type  of  loafers.  The  hard 
working  laundress  is,  as  a  rule,  a  better  shock  risk  than  is  her  idle 
employer. 

Age. — Surgeons  are  generally  agreed  that  children  are  more  sus- 
ceptible to  shock  than  adults  yet  this  increased  susceptibility  is  very 
difficult  to  estimate.  It  has  been  said  that  could  the  infant  be  operated 
on  m  its  own  ratio,  that  is  to  say,  by  Lilliputian  surgeons,  using  infan- 
tile instruments,  etc.,  and  exposing  only  proportionate  areas  to  heat, 
cold  and  traumatism  the  results  might  not  be  disproportionate  to 
those  obtained  in  the  adult.  This  is  impossible.  Therefore,  from  the 
practical  standpoint,  the  infant  and  child  require  a  special  estimate 
of  the  shock  risk  and  very  frequently  the  institution  of  special  pre- 
cautions to  guard  against  the  danger  of  shock. 


48  SURGICAL  PROGNOSIS 

Old  people  may  not  be  particularly  susceptible  to  shock  as  measured 
by  the  ordinary  standards  of  pulse  and  blood-pressure,  yet  in  them 
shock  is  relatively  much  more  dangerous  than  in  the  young  or  middle- 
aged  because  of  their  lack  of  "come  back"  or  power  to  recover  from 
what  in  individuals  with  normal  hearts  and  bloodvessels  would  amount 
to  only  temporary  disability.  Serious  shock  may  come  on  during 
operations  on  the  aged  without  its  being  recognized  either  by  the 
surgeon  or  the  anesthetist.  This  is  partly  because  it  is  difficult  to 
recognize  pulse  quality  in  the  presence  of  arteriosclerosis,  partly 
because  the  increase  in  pulse  frequently  does  not  keep  pace  with  the 
degree  of  shock  in  the  aged  as  it  does  in  the  young,  and  partly  because 
of  a  failure  to  realize  that  a  blood-pressure  of  100  to  110  mm.  is  a 
serious  matter  in  a  patient  whose  "normal"  pressure  is  160  to  170  mm. 
or  over,  while  in  a  younger  individual  a  fall  in  blood-pressure  to  100 
mm.  or  even  lower  would  be  of  little  relative  importance. 

Sepsis. — Patients  suffering  from  any  form  of  sepsis  should  be  looked 
upon  as  having  an  increased  susceptibility  to  shock,  and  yet  in  these 
cases  it  is  probable  that  the  postoperative  symptoms  often  ascribed 
to  shock  are  really  the  result  of  increased  toxin  absorption  incident 
to  manipulating  infected  tissues  and  the  breaking  down  of  natural 
barriers  against  absorption. 

The  collapse  which  frequently  follows  the  curettage  of  a  septic  .uterus 
is  not  shock  but  toxemia.  Likewise  the  grave  s}Tnptoms  which 
formerly  followed  extensive  intra-abdominal  manipulations  in  the 
presence  of  acute  infection  were  in  part  due  to  shock  and  in  part  to 
sudden  toxin  absorption. 

Recent  Severe  Illness. — A  t^q^ical  example  of  increased  susceptibility 
to  shock  is  seen  in  patients  who  have  only  partially  recovered  from  a 
severe  illness  and  who  are  operated  "before  they  have  had  time  to 
regain  their  strength." 

The  patient,  who  lying  quietly  in  bed,  has  a  normal  temperature 
and  normal  pulse  of  fair  volume  but  who  has  only  recently  recovered 
from  the  acute  stage  of  a  serious  gall-bladder  or  renal  or  other  form  of 
infection  is  a  handicapped  risk  as  regards  shock — a  risk  relatively  safe 
within  certain  limits  but  a  very  bad  risk  when  these  limits  are  exceeded 
by  a  careless  or  too  radical  surgeon. 

In  the  writer's  personal  experience  instances  of  unlooked  for  shock 
have  been  confined  largely  to  this  class  of  cases,  among  which  may  be 
mentioned  secondary  operations  for  osteomyelitis,  nephrectomies  and 
operations  for  pelvic  infections  in  which  neither  the  operative  manipu- 
lations nor  the  hemorrhage  were  sufficient  to  account  for  the  degree 
of  shock  produced.  The  possibility  of  the  shock-like  symptoms  being 
due  to  embolism  should  always  be  considered  in  this  class  of  cases. 

Cachexia. — One  of  the  most  serious  of  the  predisposing  causes  to 
shock  is  that  little  understood  state  of  metabolic  perversion  occurring 
in  the  course  of  malignant  disease  which  is  known  under  the  general 
term  cachexia.  The  vital  impairment  in  this  class  of  patients  is 
difficult  to  estimate.     Operations  in  them  are  usually  of  necessity 


PROGNOSIS  OF  THE  OPERATION  ITSELF  49 

severe.  Increased  susceptibility  to  shock  is  the  rule,  but  the  most 
important  factor  in  connection  with  the  prognosis  in  these  cases  is 
the  fact  that,  while  they  may  exhibit  only  a  relatively  slight  increased 
susceptibility  to  shock,  their  power  to  react  and  recover  is  often  almost 
nil.  Like  the  senile  individuals,  only  often  to  a  greater  extent,  they 
have  no  "come  back." 

Brain  Surgery. — First  among  the  operations  especially  liable  to  be 
accompanied  by  shock  are  those  involving  portions  of  the  central 
nervous  system.  Even  the  jarring,  incident  to  chiselling  through 
the  skull  may  produce  shock.  Sponging  of  the  exposed  meninges  is 
another  cause.  Horsley,^  Gushing^  and  others  have  pointed  out  the 
dangers  incident  to  increased  intracranial  pressure. 

Laryngeal  Operations. — In  such  operations  as  intubations,  laryngot- 
omies,  lar^^lgectomies,  intralarjTigeal  operations  of  all  sorts,  opera- 
tors have  reported  instances  of  sudden  collapse  or  death.  According 
to  Crile,  this  is  due  to  reflex  inhibition  of  the  heart  and  of  the  respira- 
tion from  mechanical  stimulation  of  some  part  of  the  superior  larjmgeal 
nerve  and  may  be  wholly  obviated  by  previously  administering  a 
physiological  dose  of  atropin  or  by  applying  a  local  anesthetic  to  the 
nerve  endings  m  the  lar}'ngeal  mucosa  or  by  injecting  the  trunk  of  the 
nerve  with  novocain. 

Intrathoracic  Operations. — Sudden  changes  in  intrathoracic  pressure 
such  as  occiu"  on  opening  empyemata,  or  to  an  even  greater  extent 
when  the  normal  pleural  ca\dty  is  opened,  are  always  liable  to  be 
accompanied  by  serious  shock. 

Blake^  has  summed  up  the  experience  gained  in  the  War  as  follows : 

"One  of  the  most  striking  observations  was  in  regard  to  wounds 
opening  the  pleural  cavity — the  so-called  sucking  wounds.  It  was 
noticed  that  with  such  a  wound  a  man  got  along  fairly  well  for  a  short 
time  and  then  rapidly  went  into  shock  and  died.  The  reason  was,  as 
we  have  seen  In  the  explanation  of  shock,  a  lack  of  oxidation  due  to 
inadequacy  of  respiration.  If  the  admission  of  air  through  the  wound 
were  stopped,  these  cases  did  as  well  as  those  with  non-sucking  wounds. 
It  became  the  rule,  therefore,  to  close  such  wounds  as  soon  as  possible, 
even  if  they  were  only  provisionally  sewed  together  and  had  to  be 
operated  on  and  reclosed  later.  It  was  found  that  if  shock  could  thus 
be  prevented  the  patient  could  subsequently  withstand  a  formal 
operation  in  the  course  of  which  the  wound  of  the  chest  wall  could  be 
excised  and  enlarged,  the  lung  withdrawn  if  necessary,  the  wounds  in 
the  latter  also  excised  and  sutured,  and  the  chest  finally  closed.  Closure 
of  the  chest,  if  only  for  a  day  or  two  to  enable  the  vital  functions  to 
become  readjusted,  was  found  imperative." 

Abdominal  Operations. — "In  abdominal  operations  the  amount  of 
shock  depends  in  direct  ratio  upon  the  trauma  and  exposure.     This 

1  British  Med.  Jour.,  1890,  iv,  1286. 

2  BWl.  Johns  Hopkins  Hosp.,  1901,  i,  ii,  290. 

'  The  Influence  of  the  War  upon  the  Development  of  Surgery,  vol.  Ixis,  May,  1919, 
p  459. 
4 


50  SURGICAL  PROGNOSIS 

territory  hears  a  rich  supply  of  vasomotor  nerves,  and  the  effect  of  a 
given  opei'ation  upon  the  vasomotor  center  is  the  sum  of  the  exposure 
to  the  air  and  the  intensity  and  number  of  mechanical  contacts  with 
the  abundant  nerve  supply  of  this  territory."     (Crile.) 

Operations  in  the  region  of  the  diaphragm,  the  common  bile  duct, 
the  pancreas  and  all  operations  involving  extensive  traumatism  of 
the  mesentery  (intestinal  resections)  are  especially  shock-producing. 
Operations  below  the  pelvic  brim  are,  as  a  rule,  less  shock-producing 
than  those  in  the  upper  abdomen. 

Operations  on  the  Extremities.- — In  operations  upon  the  extremities 
shock  may  be  almost  entirely  avoided  if  care  be  taken  to  prevent 
hemorrhage  and  to  either  avoid  injuring  the  larger  nerve  trunks  or  to 
block  the  nerves  by  intraneural  injections  of  novocain.  Nerve  block- 
ing should  be  employed  in  all  operations  upon  the  extremities  likely 
to  be  accompanied  by  shock. 

Wound  Infection. — The  whole  science  of  modern  surgery  has  devel- 
oped around  the  fact  that  except  in  war  surgery  it  lies  within  the 
power  of  the  surgeon  to  prevent  wound  infection  in  all  but  a  \'ery 
small  minority  of  the  cases  he  is  called  upon  to  treat.  In  general  it 
may  be  said  that  the  prognosis  as  regards  infection  is,  in  the  individual 
patient,  what  the  surgeon  himself  makes  it,  and  yet  experience  has 
always  shoAvn  that  no  surgeon  has  been  able  to  entirely  eliminate  this 
complication  from  his  work. 

Infection  always  increases  the  postoperative  morbidity  and  prolongs 
the  period  of  convalescence.  Not  mfrequently  it  serves  to  defeat  the 
purpose  of  the  operation  and  occasionally  an  accidental  infection 
results  in  the  death  of  the  patient.  INIost  of  the  postoperative  com- 
plications leading  to  more  or  less  serious  permanent  disability  are  the 
result  of  infection. 

Statistics  dealing  with  the  frequency  of  wound  infections  have 
for  the  most  part  been  published  with  the  idea  of  proving  the  superior- 
ity of  some  particular  aseptic  or  antiseptic  technic,  yet  when  we 
attempt  to  compile  and  compare  these  results  it  is  evident  that  the 
averages  as  reported  for  the  different  methods  are  very  nearly  the 
same  provided  the  character  of  the  operati^'e  work  is  of  approximately 
the  same  nature. 

Beckman^  reports  1.9  per  cent,  of  infections  in  a  series  of  5835 
operations  and  1.7  per  cent,  of  infections  in  another  series  of  6825^ 
operations  performed  at  the  ]\Iayo  Clinic.  This  (2  per  cent.)  is  about 
the  average  frequency  as  reported  from  ^'arious  sources. 

Operations  on  the  Extremities. — This  field  of  surgery  offers  ideal 
opportunities  for  the  carrying  out  of  an  approved  teclmic,  and  ortho- 
paedic surgeons  have  abundantly  demonstrated  that  in  civil  practice 
the  incidence  of  infection  following  operations  on  the  extremities  is 
almost  entirely  under  the  control  of  the  operator;  also,  that  there  is  no 
special  liability  to  infection  in  operations  involving  bones  and  joints 

1  Collected  Papers  by  the  Staff  of  St.  Mary's  Hospital,  1912,  pp.  738-747. 

2  Ibid.,  1913,  pp.  776-782. 


PROGNOSIS  OF  THE  OPERATION  ITSELF  51 

provided  the  manipulations  do  not  endanger  the  vitahty  of  the  tissue. 
When  infections  do  occur,  however,  as  the  result  of  operations  involv- 
ing bones  or  johits  the  prognosis  as  regards  the  effect  of  the  complica- 
tion on  the  outcome  of  the  operation  is  usually  much  more  serious  than 
after  operations  limited  to  the  soft  tissues. 

An  exception  to  the  above  rule  regarding  the  relative  freedom 
from  infections  in  operations  on  the  extremities  is  apparently  encoim- 
tered  in  the  operative  treatment  of  fractures.  The  peculiar  liability 
of  compound  fractiu-es  to  serious  infection  and  the  disastrous  conse- 
quences of  the  same  has  been  recognized  since  the  earliest  times. 
Within  recent  years  this  has  been  again  emphasized  in  connection  with 
the  open  treatment  of  fractures.  In  this  field  of  surgery,  especially 
when  buried  metal  splints  are  employed,  even  the  slightest  grades  of 
infection,  such  as  would  be  scarcely  demonstrable  in  abdominal 
surgery,  are  fraught  with  the  most  serious  consequences.  Lane  has 
demonstrated  that  infection  can  be  avoided  but  the  standard  neces- 
sary for  success  is  entirely  different  from  that  ordinarily  attained  by 
the  average  general  sm-geon,  and  failures  in  this  field  of  surgery  have 
been  frequent  and  serious. 

Operations  of  the  Head,  Face  and  Neck.- — The  face  and  scalp  are 
particularly  resistant  to  infection.  Scalp  wounds,  even  those  the 
result  of  accident,  seldom  become  infected.  Operative  wounds  in 
the  region  of  the  mouth,  even  though  they  be  made  through  fields 
impossible  of  sterilization,  heal  by  first  intention  in  the  great  majority 
of  cases. 

Although  the  technical  difficulties  of  maintaming  absolute  asepsis 
during  operations  upon  the  neck  are  considerable,  infection  in  this 
region  is  rarely  encountered  and  the  occasional  infection  which  does 
occur  is  seldom  of  much  importance.  Beckman  reports  only  26 
infections  in  2785  operations  for  goiter,  or  less  than  1  per  cent.,  and 
none  of  these  residted  seriously. 

The  Breast. — Practically  all  sm-geons  report  a  very  low  incidence 
of  infections  following  amputation  of  the  breast.  The  Halstead  t^'pe 
of  breast  amputation  exposes  a  large  surface  to  possible  mfection, 
the  field  is  frequently  difficult  of  sterilization  and  closure  of  the  skin 
defect  often  necessitates  tension  on  the  sutures  There  may  be  some 
sloughing  of  the  skin  but  noteworthy  infection  is  seldom  encountered. 

Hernia. — Beckman  reports  .31  infections  in  the  course  of  623  opera- 
tions for  ingumal  hernia  (4.9  per  cent.).  This  proportion  seems  high 
and  yet  it  is  approximately  the  average  as  reported  by  other  surgeons. 
Hilgenreiner^  has  reported  4.2  per  cent,  infections  in  1000  operations 
for  hernia  performed  between  1901  and  1910.  Sertoli,-  from  Ceci's 
Clinic,  reported  that  in  1509  operations  for  non-strangulated  hernia, 
the  wound  suppurated  in  90,  or  6  per  cent.  A  few  have  reported  better 
results  but  many  more  have  admitted  an  even  higher  percentage  of 
infection. 

iBeitr.  z.  klin.  Chir.,  December,  1910. 
2  Arch.  f.  klin.  Chir.,  1909,  No.  2. 


52  SURGICAL  PROGNOSIS 

Ventral  and  umbilical  hernias  apparently  exhibit  about  the  same 
tendency  to  infection  as  do  inguinal  hernias.  Femoral  hernias  are, 
on  the  other  hand,  rarely  accompanied  by  infection. 

Whether  the  liability  to  infection  in  hernias  be  due  to  the  difficulty 
in  sterilizing  and  dressing  the  field,  or  to  the  suture  tension  necessary 
to  close  the  defects,  or  to  the  necessity  of  using  slowly  absorbable 
suture  material,  the  fact  should  always  be  borne  in  mind  that  hernia 
operations  are  for  some  reason  particularly  liable  to  infection. 

Gynecological  Operations. — Laparotomies  for  tubal  and  ovarian 
conditions,  shortening  the  round  ligaments  and  other  minor  gynecolog- 
ical conditions  are  seldom  accompanied  by  infection.  Subtotal  hys- 
terectomy adds  a  slight  risk  possibly  due  to  increased  tramnatism 
and  possibly  due  to  opening  the  cavity  of  the  uterus.  On  the  other 
hand,  total  abdominal  hysterectomy  yields  a  large  percentage  of 
infections  (7  per  cent.  Beckman),  due  to  the  fact  that  the  vagina  often 
harbors  virulent  organisms  in  cases  requiring  total  hysterectomy,  while 
at  the  same  time  unavoidable  trauma  incident  to  the  operation  leaves 
a  field  susceptible  to  bacterial  invasion. 

In  spite  of  the  fact  that  it  is  impossible  to  secure  an  actually  sterile 
field  in  vaginal  operations,  infections  interfering  with  the  results  of 
operations  on  the  cerA'ix  or  perineum  are  seldom  encountered,  although 
perfect  primary  union  in  the  sense  used  when  speaking  of  abdominal 
wounds  is  frequently  not  obtained.  Formerly  the  writer  used  great 
care  in  sterilizing  the  vagina  but  in  a  certain  percentage  of  cases  it 
was  apparent  that  the  normal  harmless  bacteria  inhabiting  this  region 
were  removed  only  to  have  it  reoccupied  soon  after  the  operation  by  new 
species  toward  which  the  body  had  not  had  an  opportunity  to  de^'elop 
an  immunity.  During  the  past  six  years  I  have  made  no  effort  to 
sterilize  the  vagina  other  than  a  simple  cleansing  with  soap  and  water, 
and  I  am  certain  that  the  healing  in  vaginal  cases  has  been  far  better 
than  when  we  disturbed  the  truce  existing  between  the  body  and  the 
normal  vaginal  flora. 

Intestinal  Tract. — The  danger  of  infection  by  intestinal  bacteria  in 
all  operations  on  the  intestinal  tract  is  self-evident.  Under  ordinary 
conditions  in  otherwise  clean  laparotomies  the  incidental  removal  of 
the  appendix  seems  to  approximately  double  the  liability  to  infection. 
In  this  connection  it  is  worthy  of  note  that  whereas  most  surgeons  use 
great  care  in  handling  the  stump  of  the  appendix  itself  most  of  them 
fail  to  appreciate  the  fact  that  the  needle  and  suture  used  in  inverting 
the  stump  is  usually  promptly  infected  by  passing  it  through  all  coats 
of  the  cecum,  and  that  the  suture  and  the  objects  coming  in  contact 
with  it  should  thereafter  be  looked  upon  as  infected.  With  proper 
attention  to  this  detail,  we  believe  that  the  extra  risk,  due  to  appen- 
dectomy in  otherwise  clean  cases,  can  be  eliminated. 

Beckman  reports  5.7  per  cent,  of  infections  in  750  operations  on  the 
stomach,  and  according  to  data  from  other  sources  from  5  to  10  per 
cent,  would  seem  to  be  a  fair  a^'e^age.  These  infections  in  stomach 
cases  rarely  result  in  fatal  complications,  but  they  do  frequently  result 
in  ventral  hernia. 


PROGNOSIS  OF  THE  OPERATION  ITSELF  53 

Operations  on  the  large  bo'^'el  are  accompanied  by  some  infection 
in  a  large  percentage  of  cases,  and  in  the  surgery  of  the  large  intestine 
more  frequently  than  in  any  other  branch  of  abdominal  surgery, 
infection  is  liable  to  lead  to  fatal  complications. 

The  Peritoneum. — The  ability  of  the  peritoneum  to  resist  infection 
is  not  surpassed  by  any  other  tissue  in  the  body.  In  estimating  the 
possibilities  of  a  peritoneal  infection  occurring  as  the  result  of  an 
operation,  laparotomies  may  be  divided  into  three  classes:  (1)  Those 
cases  in  which  the  operation  is  performed  for  a  condition  other  than  an 
active  infection,  and  in  which  no  infected  cavities  are  invaded  during 
the  course  of  the  operation.  In  this  group  are  included  hernia  opera- 
tions, many  gynecological,  a  certain  proportion  of  gall-bladder  opera- 
tions and  other  miscellaneous  laparotomies.  (2)  Operations  in  which 
no  active  infection  is  present  but  in  which  infected  or  possibly  infected 
cavities  are  invaded  diu-ing  the  coiu-se  of  the  operation.  Appendec- 
tomies, hysterectomies,  operations  upon  the  gastro-intestinal  tract 
and  some  of  the  operations  on  the  biliary  and  urinary  tracts  should 
be  included  in  this  group.  (3)  Operations  undertaken  for  the  relief 
of  active  intraperitoneal  infections. 

In  the  first  group  serious  accidental  infection  of  the  peritoneum  is 
one  of  the  rarest  accidents  in  surgery.  In  the  second  group  note- 
worthy oeritoneal  infection  is  only  very  rarely  encountered  in  simple 
appendectomies,  gall-bladder  operations  or  hysterectomies.  With 
good  technic  it  is  also  rare  after  operations  on  the  stomach  and  upper 
intestinal  tract.  On  the  other  hand,  operations  involving  resection 
of  portions  of  the  large  intestine  are  frequently  accompanied  by 
serious  peritoneal  infection.  In  the  third  group  modem  technic  aim- 
ing to  protect  and  assist  the  peritoneum  in  its  fight  against  the  already 
existing  hifection  has  to  a  considerable  extent  lessened  the  danger  of 
the  infection  being  spread  as  the  result  of  the  operation.  In  these 
cases  the  danger  is  greatest  during  the  height  of  the  infection  and 
decreases  rapidly  after  the  subsidence  of  the  acute  stage  of  the  inflam- 
matory^ process,  so  that  in  subacute  and  chronic  cases  abscesses  may 
be  opened  and  drained  through  incisions  openmg  into  the  general 
peritoneal  cavity  with  surprisingly  little  danger  of  extending  the 
area  of  infection. 

Except  after  operations  on  the  large  intestine  cases  of  postoperative 
general  peritonitis,  such  as  were  rather  frequently  encountered  by 
the  pioneers  in  abdominal  surgery,  are  now  almost  always  due  to 
gross  accidents,  such  as  overlooking  rents  or  fistulous  openings  in  the 
intestines,  faulty  intestinal  suturing  or  improperly  placed  drainage, 
allowing  pus,  bile  or  lu-ine  to  escape  directly  into  the  peritoneal  cavity. 

Incisions  Made  for  the  Purpose  of  Treating  Infections. — In  operations 
undertaken  for  the  treatment  of  acute  inflammatory  conditions  the 
incisions  are  necessarily  exposed  to  infection,  and  the  question  of  the 
extension  of  the  infection  to  such  incisions  is  of  considerable  practical 
unportance.  In  general  it  may  be  said  that  if  the  primary  focus  of 
infection  is  thoroughly  drained,  that  portion  of  the  incision  which  is 
sutured  at  the  close  of  the  operation  will  heal  by  primary  union. 


54  SURGICAL  PROGNOSIS 

In  the  writer's  experience  abdominal  drainage  cases  operated  during 
the  acute  stages  of  an  intraperitoneal  infection  have  yielded  a  much 
higher  proportion  of  wound  infections  than  have  cases  operated  after 
the  subsidence  of  the  acute  stage,  even  though  pus  was  encountered 
at  the  time  of  the  operation.  This  is  probably  due  chiefly  to  the  fact 
that  in  the  later  operations  an  acquired  immunity  has  been  developed 
against  the  organisms  responsible  for  the  infection.  At  a  still  later 
period  the  pus  may  be  sterile  or  the  organisms  may  have  lost  their 
virulence. 

A  considerable  proportion  of  the  more  troublesome  wound  infections 
has  been  in  patients  operated  for  acute  intraperitoneal  lesions  in  which 
the  abdomen  was  closed  without  drainage,  or  in  abscess  cases  in  which 
the  drainage  was  carried  through  a  lateral  stab  wound  without  pro- 
viding for  adequate  drainage  of  the  principal  incision.  In  the  first 
group  the  peritoneum  has  had  no  difficulty  in  overcoming  the  infection 
which  in  less  resistant  tissues  has  been  sufficient  to  break  down  the 
abdominal  incision.  In  the  second  class  of  cases  the  closure  of  the 
chief  incision  with  the  use  of  a  lateral  stab  wound  for  drainage  has  not 
only  been  unsatisfactory  as  regards  healing  but  has  resulted  in  more 
ventral  hernias  than  would  probably  have  occurred  had  the  drainage 
been  brought  out  through  one  end  of  the  original  incision  because 
without  drainage  the  chief  incision  has  broken  down. 

Accidental  Wounds. — Infection  in  wounds  of  the  industrial  accident 
type  is  dependent  uix)n  a  number  of  factors.  Cuts  and  simple  lacera- 
tions are  much  less  liable  to  become  infected  than  are  open  wounds 
accompanied  by  considerable  crushing  of  the  soft  parts.  The  char- 
acter of  the  surroundings  in  which  the  accident  happens  is  also  a  very 
important  factor.  The  grease  and  dirt  of  the  machine  shop  is  seldom 
the  habitat  of  virulent,  pathogenic  organisms.  On  the  other  hand, 
street  dirt  usually  contains  organisms  capable  of  causing  infection. 
Ambulances,  doctors'  offices  and  dispensaries  are  always  dangerous 
localities,  and  before  an  accident  case  is  allowed  to  enter  any  one  of 
these  highly  infected  regions  open  wounds  should  always  be  covered 
with  a  sterile  first-aid  dressing. 

The  possibility  of  effectually  sterilizing  the  field  of  traumatism 
after  an  accident  is  a  question  still  open  to  discussion.  Some  surgeons 
believe  in  very  vigorous  use  of  mechanical  and  antiseptic  methods  of 
cleansing  the  wound.  Others  believe  that  the  really  essential  point 
is  to  preserve  the  vitality  of  the  tissues  and  that  whatever  is  done  in 
the  way  of  a  toilet  of  the  wound  the  tissues  should  not  be  subjected 
to  further  mechanical  or  chemical  traumatism.  The  success  attend- 
ing the  use  of  tincture  of  iodin  in  these  cases  is  probably  dependent 
largely  upon  its  simplicity  and  relative  harmlessness  as  compared 
with  more  complicated  methods  formerly  employed. 

In  general  it  may  be  said  that  a  siuprisingly  large  percentage  of 
accidental  wounds  heal  without  suppiuation  and  that  in  the  absence 
of  pathogenic  germs  gaining  access  to  the  wound  after  the  patients 
come  under  treatment,  serious  infections  are  but  seldom  encountered. 


PROGNOSIS  OF  THE  OPERATION  ITSELF  55 

War  Wounds. — One  of  the  lessons  of  the  late  World  War  was  the  fact 
that  civil  experience  and  war  experience  are  entirely  different  as  regards 
the  frequency  of  wound  infections.  The  great  liability  of  infection 
and  the  factors  governing  the  same  will  be  described  in  other  chapters 
of  this  book. 

Postoperative  Puhnonary  Complications. — Postoperative  pulmonary 
complications  may  be  classified  in  five  groups  (Beckman) : 

1.  Acute  Postoperative  Congestion  of  the  Lungs. — This  condition  is 
characterized  by  an  excess  of  secretion  in  the  air  passages.  It  is  usu- 
ally most  noticeable  immediately  after  the  operation  and  subsides  in 
a  few  hours.     As  a  rule,  it  has  little  or  no  effect  on  the  prognosis. 

2.  Pleurisy. — This  is  a  relatively  frequent  minor  complication. 
The  symptoms  last  from  a  few  days  to  a  week,  rarely  longer.  Serious 
results  are  very  rarely  observed. 

3.  Bronchitis. — ^This  is  the  most  frequent  of  the  postoperative  pul- 
monary complications.  The  acute  symptoms  usually  subside  in  a 
few  days  and  serious  results  are  rarely  encountered,  although  the 
discomfort  produced  by  the  coughing  is  often  considerable.  Occa- 
sionally the  extra  strain  placed  on  the  suture  line  in  abdommal  cases  is 
the  cause  of  a  subseciuent  ventral  hernia. 

4.  Bronchopneumonia  and  5,  Lobar  Pneumonia. — ^Pneumonia  is  one 
of  the  most  serious  of  the  postoperative  complications.  Clinically  it 
is  often  difficult  to  separate  the  two  forms  of  the  disease,  and  in  most 
of  the  statistical  studies  dealing  with  pneumonia  as  a  postoperative 
complication  no  attempt  has  been  made  to  separate  them.  The 
frequency  of  this  complication  varies  in  statistics  from  different 
sources  due  probably  in  a  large  measure  to  the  different  character 
of  the  material  analyzed  in  compiling  the  statistics. 

In  America  postoperative  pneumonia  is  a  rare  complication.  Thus, 
Beckman,^  Anders-  and  Miller'  report  37,132  operations  followed  by 
103  cases  of  pneumonia,  or  1  case  of  pnemnonia  for  each  360  cases 
operated.  Beckman  and  Anders  report  24  deaths  from  pneumonia 
following  30,132  operations,  or  1  death  for  each  1255  cases  operated. 

These  results  are  in  sharp  contrast  to  the  often  quoted  statistics 
of  Mikulicz,*  Henle,^  Gibele^  and  Czerny,^  which  may  be  summarized 
as  follows: 

Miktilicz 1278  operations  with  110  pneumonias. 

Henle 1987  "  "     145 

Gebele 1196  "  "       54 

Czerny 1300  "  "       52 

1  Northwestern  Lancet,  May  15,  1911;  Ann.  Surg.,  1913,  vii,  718-729;  Collected 
Papers  by  the  Staff  of  St.  Mary's  Hospital,  1913,  pp.  784-785. 

2  University  Med.  Mag.,  Philadelphia,  1897-1898,  x,  641-666. 

3  Kelly  and  Noble's  Gyn.  and  Abd.  Surg.,  1910,  ii,  35. 

« Pneumonie,  Verhand.  d.  XXX  Kongr.  der  Deutsch.  Gesellsch.  f .  chir.  Centralbl.  f. 
Chir.,  1901,  No.  29,  p.  16. 

5  Ueber  Pneumonie  und  Laparotomie,  Arch.  f.  klin.  Chir.,  xliv,  Heft  2. 

6  Beitr.  z.  klin.  Chir.,  xliii,  Heft  2,  251-318. 

^  Cited  by  Miller  in  Kelly  and  Noble,  loc.  cit. 


56  SURGICAL  PROGNOSIS 

The  great  majority  of  the  above  operations  were  laparotomies  and 
Continental  surgeons  only  a  few  years  ago  insisted  that  pneumonia 
was  to  be  expected  after  laparotomy  in  about  5  per  cent,  of  the  cases. 
This  figure  is  certainly  from  five  to  ten  times  greater  than  the  average 
American  frequency  following  abdominal  operations.  Robb  and 
Dittrick/  after  1007  abdominal  operations,  found  only  3  cases  of 
pneumonia,  while  Mallett,^  after  1700  laparotomies  found  7  cases  of 
pneumonia. 

The  exact  relationship  between  the  anesthetic  and  the  pulmonary 
group  of  postoperative  complications  has  never  been  definitely  deter- 
mined. The  terms  "ether  pneumonia"  and  "ether  bronchitis"  are 
very  frequently  used.  Yet  before  the  discovery  of  anesthesia,  lung 
complications  caused  a  high  mortality  after  operation,  and  modern 
statistics  dealing  with  the  frequency  of  these  diseases  fail  to  show  any 
clearly  defined  relationship  between  the  anesthesia  and  the  pulmonary 
complication. 

The  figures  reported  by  Mikulicz^  are  typical.  He  states  that  at 
the  Breslau  Clinic  in  1005  laparotomies  and  operations  for  strumous 
affections  under  general  anesthesia  there  was  a  pneumonic  morbidity 
of  7.5  per  cent,  with  a  mortality  of  3.4  per  cent.  In  273  cases  operated 
under  local  anesthesia  (Schleichs's  method)  there  was  a  morbidity  of 
12.8  per  cent,  and  a  mortality  of  4.8  per  cent,  due  to  pneumonia. 
These  results  do  show  that  great  care  should  be  exercised  in  placing 
the  blame  on  the  anesthetic,  yet  local  anesthesia  was  used  in  a  con- 
siderable proportion  of  these  273  cases  because  of  the  known  liability 
of  the  individual  cases  selected  to  pneumonia  if  operated  under  general 
anesthesia.  The  pulmonary  mortality  might  have  been  considerably 
higher  under  general  anesthesia.  I  know  of  no  trustworthy  statistics 
on  this  subject  comprising  large  groups  of  similar  cases  operated  under 
different  methods  of  anesthesia. 

As  a  matter  of  fact  the  incidence  of  postoperative  pneumonia  depends 
very  largely  upon  the  age  and  general  condition  of  the  patient  and  the 
character  of  the  disease  for  which  the  patient  is  operated.  Fatal 
pneumonia  may  follow  the  simplest  operation  on  a  patient  in  the 
prime  of  life  and  apparently  in  the  best  of  health,  but  such  accidents 
are  extremely  rare.  Past  middle  age  the  danger  of  pneumonia  increases 
directly  with  the  age  of  the  patient  until  in  the  very  old  the  danger 
becomes  so  great  as  to  be  one  of  the  chief  causes  of  surgical  mortality. 
Likewise  in  the  severely  septic  and  the  debilitated  from  any  cause, 
particularly  alcoholism,  the  dangers  of  pneumonia  are  greatly  increased. 
Operations  on  the  stomach  and  gall-bladder  are  said  to  be  specially 
liable  to  be  followed  by  pulmonary  complications. 

The  inspiration  of  material  into  the  lungs  during  an  operation 
greatly  increases  the  danger  of  bronchopneumonia, 

1  Cited  by  Miller,  loc.  cit.  t 

2  Am.  Jour.  Obst.,  April,  1905,  p.  516. 

^  Pneumonie,  Verhand.  d.  XXX  Kongr.  der  Deutsch.  GeselLsch  f.  Chir.  Centralbl.  f. 
Chir.,  1901,  No.  29,  p.  16. 


PROGNOSIS  OF  THE  OPERATION  ITSELF  57 

TABLE   IV. — SHOWING   KELATIVE  FREQUENCY  OF  THE  DIFFERENT 
PULMONARY   COMPLICATIONS. 


MiUer 

Bronchitis. 
.       .       .       .       18 

Pneumonia. 

17 

3 

20 

56 

96 

Pleurisy. 
16 

Robb  and  Dittrick 

Armstrongi 

Beckman       ...... 

....      18 
....      19 
.      .      .      .     72 

9 

5 

55 

127 

85 

Embolism. — With  the  gradual  reduction  of  operative  mortality  due 
to  other  causes,  embolism  has  assumed  a  place  of  constantly  mcreasing 
relative  importance,  until  today  it  is  one  of  the  important  causes  of 
surgical  mortality. 

The  great  majority  of  cases  of  fatal  postoperative  embolism  are 
due  to  the  sudden  plugging  of  a  vessel  of  the  lung  (pulmonary  embo- 
lism) with  a  clot  originating  in  the  field  of  operation  or  femoral  vein. 
Occasionally  the  clot  may  originate  in  a  vessel  other  than  the  femoral 
at  some  distance  from  the  field  of  operation  or  in  the  heart  itself. 
Occasionally  the  clot  may  lodge  in  the  brain  (cerebral  embolism)  or  in 
the  heart  (cardiac  or  coronary  embolism) ,  Embolism  involving  other 
organs  notably  the  kidneys,  spleen  or  intestines  is  frequently  observed 
at  autopsy  but  is  seldom  recognized  clinically.  The  smaller  pulmon- 
ary emboli,  such  as  are  so  frequently  found  at  autopsy,  are  probably 
responsible  for  many  cases  of  so-called  pleurisy.  Fat  embolism  and 
air  embolism  will  be  discussed  under  separate  heads. 

Wilson^  calls  attention  to  the  following  general  considerations 
concerning  the  subject  of  postoperative  embolism: 

"1.  Following  operation,  particularly  on  the  bloodvessels,  aliment- 
ary canal  and  genito-urinary  organs  (both  male  and  female),  from 
1  to  2  per  cent,  of  aU  cases  give  more  or  less  distinct  clinical  evidence 
of  emboli,  above  70  per  cent,  of  which  are  in  the  lungs. 

"2.  As  nearly  as  can  be  observed  from  the  incomplete  and  neces- 
sarily inaccurate  data  at  hand,  about  10  per  cent,  of  postoperative 
emboli  which  give  clinical  symptoms  of  diagnostic  significance  cause 
sudden  death. 

"3.  \^Tiere  postmortems  are  made  on  cases  of  fatal  postoperative 
embolism,  the  source  of  the  emboli  can  be  definitely  determined  as 
venous  thrombosis  in  about  80  per  cent,  of  the  cases,  as  cardiac  throm- 
bosis in  10  per  cent,  of  the  cases,  while  10  per  cent,  are  scattering  or 
undeterminable. 

"4.  Though  there  must  be  more  or  less  formation  of  venous  thrombi 
at  the  site  of  every  extensive  surgical  operation,  yet  it  is  probable 
that  the  long,  loosely-formed  thrombi  from  the  mediiun-sized  veins 
are  those  chiefly  concerned  in  embolism,  and  especially  in  fatal 
embolism. 

1  Lung  Complications  after  Operations  with  Anesthesia,  British  Med.  Jour.,  1906,  i, 
1141. 

2  Fatal  Postoperative  Embolism,  Ann.  Surg.,  December,  1912. 


58  SURGICAL  PROGNOSIS 

"  5.  When  large,  loose  thrombi  are  once  formed  in  a  resting  patient, 
any  unusual  exertion  or  change  of  position  may  cause  a  dislocation  of 
large  masses  which  become  dangerous  emboli." 

The  mortality  from  embolism,  based  on  the  63,573  operations 
reported  by  ^Yilson  is  0.07  of  1  per  cent.,  or  1  death  in  every  1352 
operations.  When  the  cases  are  grouped  according  to  the  anatomical 
regions  on  which  the  preceding  operation  was  done,  they  are  found 
to  be  as  follows: 

After  1372  operations  on  bloodvessels,  2  deaths,  or  0.14  of  1  per  cent. 

After  3266  operations  on  the  thyroid,  2  deaths,  or  0.06  of  1  per  cent. 

After  2281  operations  on  the  mouth,  1  death,  or  0.05  of  1  per  cent. 

After  2391  operations  on  the  stomach  or  duodenum,  3  deaths,  or 
0.12  of  1  per  cent. 

After  4597  operations  on  the  gall-bladder,  9  deaths,  or  0.19  of  1  per 
cent. 

After  389  operations  on  the  small  intestine,  1  death,  or  0.26  of  1  per 
cent. 

After  9908  operations  on  the  appendix,  4  deaths,  or  0.04  of  1  per 
cent. 

After  2530  operations  on  the  colon  and  rectum,  5  deaths,  or  0.20  of 
1  per  cent. 

After  4501  operations  on  hernia,  5  deaths,  or  0.11  of  1  per  cent. 

After  900  operations  oti  the  kidney,  1  death,  or  0.11  of  1  per  cent. 

After  601  operations  on  the  prostate,  4  deaths,  or  0.66  of  1  per  cent. 

After  7993  operations  on  the  uterus,  tubes  and  ovaries,  10  deaths, 
or  0.13  of  1  per  cent. 

After  1346  operations  on  the  breast,  no  deaths. 

After  449  vaginal  hysterectomies,  no  deaths. 

After  1712  abdominal  hysterectomies,  5  deaths,  or  0.29  of  1  per 
cent. 

These  figures  in  themselves  fail  to  show  any  particular  liability  to 
embolism  in  any  special  field  of  operative  work  except  possibly  opera- 
tions on  the  prostate  and  supravaginal  hysterectomy.  In  this  con- 
nection it  has  long  been  known  that  cases  of  prostatectomy  and 
operations  for  uterine  myomata  are  especially  liable  to  be  fjllowed 
by  pulmonary  embolism. 

The  frequency  of  fatal  embolism  as  given  by  Wilson  is,  for  the  most 
part,  lower  than  that  given  by  others  who  have  studied  the  subject. 
While  the  material  analyzed  is  not  strictly  comparable,  the  discrepan- 
cies in  the  data  from  different  sources  is  best  indicated  in  the  following 
manner : 

Wilson,  63,573  operations,  47  deaths  from  emboli. 

Oppenheim,!  6871  operations,  23  deaths  from  emboli. 

Wilson,  9908  operations  on  appendix,  4  deaths  from  emboli. 

Howard,^  3774  operations  on  appendix,  8  cases  of  pulmonary  embo- 
lism. 

1  Berl.  Idin.  Wchnschr.,  1902. 

2  Phlebitis  and  Thrombosis,  1906,  p.  41. 


PROGNOSIS  OF  THE  OPERATION  ITSELF  59 

The  following  figures  show  the  recognized  frequency  of  embolism 
as  reported  from  different  sources: 

Per  cent. 

Gebele.i  1196  laparotomies,  embolism  in 1.17 

Lowen,!  1203  laparotomies,  embolism  in 0.75 

Wolff,!  1806  operations,  embolism  in 0.49 

Bibergeil,!  3909  laparotomies,  embolism  in 0.30 

Albanus.i  1140  laparotomies,  embolism  in 0.20 

Sorrenburg,2  2000  appendix  operations,  embolism  in 5.30 

Oppenheim, 3  6871  operations,  embolism  in 0.82 

Kronig,^  391  myoma  operations,  embolism  in 0.50 

Burkhardt,'*  236  myoma  operations,  embolism  in 5.00 

Frieberg  Klinic*  2265  laparotomies,  embolism  in  (deaths)       .      .      .      .  0.10 

V.  Winczel, 5  836  laparotomies,  embolism  in 1.20 

Stanton, 6  1573  operations,  embolism  in  (deaths) 0.13 

Sertoli,''  1543  herniotomies,  embolism  in  (deaths) 0.20 

Fat  Embolism  {Traumatic  Lipeviia). — Fat  embolism  is  a  possible 
complication  after  all  bone  injuries  and  after  orthopedic  operations 
and  manipulations.  In  the  past  it  has  been  looked  upon  as  a  patho- 
logical curiosity,  and  yet  the  observations  of  Warthin^  and  others 
would  seem  to  indicate  that  a  fairly  large  proportion  of  the  deaths 
following  traumatisms  and  commonly  ascribed  to  such  causes  as  shock, 
heart  failure,  acute  cardiac  dilatation,  cerebral  hemorrhage,  pneu- 
monia, sepsis,  insanity,  alcoholism,  etc.,  are  really  examples  of  fat 
embolism.  Out  of  12  cases  of  fatal  traumatic  lipemia  autopsied  by 
Warthin  the  real  cause  of  death  had  been  suspected  in  only  1  case, 
and  yet  all  had  occurred  in  the  services  of  clinicians  of  the  highest 
standing. 

BisselP  in  a  review  of  clinical  and  experimental  data  from  the  IMayo 
Clinic  has  shown  that  fat  embolism  is  one  of  the  really  important  causes 
of  serious  postoperative  complications  often  closely  simulating  simple 
shock. 

Air  Embolism. — This  accident  is  so  rare  as  to  have  practically  no 
effect  on  prognosis.  Nevertheless,  its  possibility  should  always  be 
borne  in  mind  when  operating  in  regions  where  there  may  be  a  negative 
venous  blood-pressure  during  inspiration. 

With  the  patient  lying  flat  on  the  operating  table  the  region  of 
danger  is  practically  limited  to  the  subclavian  and  the  lower  third 
of  the  jugular  veins.  With  the  head  elevated  to  the  semi-sitting 
posture  the  danger  in  head  and  neck  operations  is  considerably 
increased.  In  this  position  air  embolism  may  follow  opening  one  of 
the  cranial  sinuses  as  well  as  any  of  the  large  venous  trunks  of  the  neck. 

1  Quoted  by  Beneke,  Die  Embolie,  in  Krehl  and  Morehead,  Handbuch  der  Allgemeinen 
Pathologic,  1913,  Pt.  2,  vol.  ii. 

2  Arch.  f.  klin.  Chir.,  1902,  vol.  Ix^iii.  ^  gerl.  klin.  Wchnschr.,  1902. 
*  In  Aschoff  and  others,  Beitr.  2air  Thrombosfrage,  Leipzig,  1912. 

5  Thrombose  und  Embolie  nach  Gynakologischen  Oper.,  Beitr.  z.  klin.  Chir.,  1913, 
Ixxxiv,  37-46. 

6  Albany  Med.  Ann.,  August,  1914.  ^  Arch.  f.  kHn.  Chir.,  1909,  No.  2. 

8  Traumatic  Lipemia  and  Fatty  Embolism,  International  Clinics,  1913,  23d  series,  iv, 
171-227. 

9  Pulmonary  Fat  Embolism,  a  Frequent  Cause  of  Postoperative  Surgical  Shock. 
Collected  papers  of  the  Mayo  Clinic,  ix,  1917,  535-559. 


60  SURGICAL  PROGNOSIS 

With  the  patient  in  the  Trendelenburg  position  air  embolism  may 
follow  g^Tiecological  operations,  but  this  is  very  rare. 

Of  33  cases  collected  by  Cauty/  in  1876,  the  point  of  entrance 
was  in  the  external  jugular  nine  times,  in  the  axillary  eight  times, 
in  the  internal  jugular  five  times,  in  the  subscapular  three  times, 
in  the  facial  occipital,  anterior  jugular  and  anterior  thoracic,  each 
twice.  The  accident  occurs  with  the  greatest  frequency  after  opera- 
tions for  the  removal  of  tumors  from  the  neck  and  axilla. 

Cases  have  been  reported  from  the  use  of  air  dilatation  in  the 
bladder,  uterus  and  the  knee-joint. 

The  recent  extensive  use  of  intravenous  medication  has  yielded  an 
occasional  fatality  from  air  embolism. 

Embolism  Due  to  Miscellaneous  Causes. — The  use  of  paraffin  injec- 
tions to  correct  nasal  deformities  has  resulted  in  a  number  of  reported 
cases  of  paraffin  embolism.  The  use  of  Beck's  paste  in  the  treatment 
of  sinuses  has  also  been  followed  by  s^^nptoms  of  embolism.  Intra- 
muscular injections  of  oily  suspensions  of  mercury  and  other  sub- 
stances has  occasionally  resulted  in  embolism. 

Phlebitis. — Its  comparative  frequency  and  distressing  after-results 
combine  to  make  phlebitis  one  of  the  most  troublesome  of  the  post- 
operative complications.  It  is  also  met  with  after  labor,  occasionally 
after  non-operative  traumas  and  after  certain  of  the  mfectious  diseases, 
notably  t\-phoid  fever. 

In  232  cases  collected  by  Cordier-  the  vessels  involved  were  as 
follows : 

The  left  saphenous  or  femoral  vein  affected 213 

Both  right  and  left  veins  affected 8 

The  right  veins  alone  affected 11 

The  proximal  part  of  vein  first  affected 182 

The  distal  part  of  vein  first  affected 36 

Schenek^  reports  566  cases  following  49,161  operations  (1.15  per 
cent.)  which  gives  a  general  idea  of  its  frequency. 

In  surgical  work  it  occurs  most  frequently  after  laparotomies  and 
hernia  operations,  and  only  rarely  after  extraperitoneal  operations  as 
is  shown  by  the  following  data  compiled  by  the  writer. 

Operations. 

Laparotomies 17,090 

Herniotomies 1,669 

Miscellaneous  extraperitoneal  operations    .         6,121 

All  authors  agree  that  it  is  several  times  more  frequent  following 
operations  for  myoma  uteri  than  any  other  laparotomies. 

The  232  cases  collected  by  Cordier  occurred  after  the  following 
operations  the  number  of  times  stated: 

1  Arch.  d.  Physiol.,  1876. 

*  Phlebitis  FoUo-s\-ing  Abdominal  and  Peh-ic  Operations,  Jour.  Am.  Med.  Assn.,  1905, 
xlv,  1792-1797. 

3  Thrombosis  and  Embolism  Following  Operations  and  Childbirth,  Tr.  Am.  Gynec. 
Soc,  1913,  xxx^-iii,  295-311. 


Phlebitis. 

Per  cent. 

280 

1.63 

13 

0.8 

8 

0.13 

PROGNOSIS  OF  THE  OPERATION  ITSELF  61 

Hysterectomy  for  fibroids — so-called  aseptic  cases 69 

Abdominal  and  pelvic  operations — character  not  stated 56 

Appendectomy — mostly  so-called  aseptic  cases 27 

Oophorectomy — cystic,  cirrhotic,  etc 16 

Pelvic  operations — character  not  stated 9 

Vaginal  hysterectomy  for  cancer 9 

Nephrorrhaphy 9 

Vaginal  operations — character  not  stated 8 

Suspension  of  uterus 7 

Cholecystotomy 4 

Hernia 4 

Ectopic  pregnancy 4 

Alexander's  operation 3 

Splenectomy , 1 

From  various  sources  the  writer  has  compiled  the  following  figures 
which  give  an  approximate  indication  of  the  relative  frequency  of 
phlebitis  after  several  frequently  performed  operations: 

Operations.        Thrombosis.        Per  cent. 

Operations  for  myoma  uteri 3,416  108  3.1 

Intraperitoneal  pelvic  operations  other  than 

for  myoma 1,369  15  1.1 

Appendectomy 5,959  77  1.6 

Operations  on  gall-bladder 821  4  0.46 

Operations  on  stomach  and  intestines        .      .  689  2  0.3 

Operations  for  inguinal  hernia 1,323  9  0.67 

Operations  for  ventral  hernia 243  4  1.6 

Operations  for  femoral  hernia 103  0  0.0 

Labor 96,000.  381  0.4 

Ultimate  Prognosis. — There  is  very  little  data  available  concerning 
the  ultimate  prognosis  of  crural  thrombosis.  Schenek  studied  the 
late  histories  of  29  patients,  8  of  them  had  symptoms  for  about  four 
months  and  subsequently  no  trouble;  2  had  some  difficulty  in  walking 
for  about  twelve  months  and  then  completely  recovered;  19  never 
fully  recovered,  being  troubled  with  swelling  and  with  more  or  less 
pain  after  being  on  their  feet  more  than  usual.  On  the  basis  of  these 
cases,  he  assumes  that  about  65  per  cent,  of  the  patients  never  fully 
recover,  and  that  if  complete  restoration  is  to  follow  it  will  come  before 
the  end  of  the  first  year,  by  which  time  the  collateral  circulation  is  as 
completely  established  as  it  ever  will  be. 

Without  quoting  definite  figures  other  surgeons  express  essentially 
the  same  opinion  concerning  the  ultimate  effects  of  phlebitis. 

There  is  considerable  divergence  of  opinion  concerning  the  frequency 
,  of  embolism  in  cases  with  phlebitis.  Among  the  233  cases  studied  by 
Cordier  there  were  6  cases  with  pulmonary  sjmiptoms  possibly  refer- 
able to  emboli  and  three  cases  of  sudden  death.  The  same  operations 
which  are  most  frequently  followed  by  phlebitis  are  also  the  ones 
most  frequently  followed  by  embolism  although  the  two  complications 
may  not  occur  in  the  same  patients.  Clinics  reporting  a  high  fre- 
quency of  phlebitis  also  have  a  high  frequency  of  embolism,  showing 
that  there  is  a  common  etiological  factor  for  the  two.  It  is  worthy  of 
note  that,  in  spite  of  a  general  belief  in  the  infectious  origin  of  throm- 
bosis, most  cases  occur  following  so-called  aseptic  operations,  and 


62  SURGICAL   PROGNOSIS 

recent  investigations^Kronig,  Aschoff,  v,  Wenszel — all  agree  that 
blood  stasis  is  probably  a  more  important  etiological  factor  in  phlebitis 
than  is  infection. 

Peritoneal  Adhesions. — The  real  importance  of  adhesions  as  a  cause 
of  distressing  sym])toms  following  laparotomies  is  difficult  to  estimate. 
Probably  the  majority  of  abdominal  surgeons  consider  them  as  among 
the  greatest  evils  associated  with  their  work.  Many  believe  that 
they  are  the  principle  cause  of  invalidism  following  laparotomies. 
On  the  other  hand,  it  is  very  easy  to  overestimate  the  importance  of 
postoperative  adhesions.  Their  presence  is  by  no  means  confined  to 
the  unsuccessful  cases  and  their  almost  constant  presence  after  laparot- 
omies makes  them  a  most  convenient  excuse  for  the  surgeon  seeking 
to  justify  a  poor  result. 

In  this  connection  it  is  a  fact  worth  noting  that  patients  oper- 
ated for  definite  pathological  conditions  of  a  character  constantly 
associated  with  adhesions,  such  as  appendicitis  with  abscess, 
pelvic  inflammatory  conditions  and  acute  cholecystitis,  seldom  com- 
plain of  serious  symptoms  due  to  this  cause,  while  the  neuras- 
thenic operated  for  what  amounts  to  practically  nothing  is  more  than 
likely  to  be  greatly  troubled  with  "adhesions."  An  extensive  study 
of  the  causes  of  poor  end-results  in  abdominal  surgery  seems  to  indicate 
that  while  adhesions  are  frequently  of  great  importance  they  are 
altogether  too  frequently  used  as  a  refuge  behind  which  the  surgeon 
hides  his  mistakes  in  diagnosis  and  surgical  judgment. 

Experience  has  taught  that  although  the  factors  underlying  their 
formation  are  fairly  well  known,  those  determining  the  persistence  of 
adhesions  are  as  yet  very  imperfectly  understood.  The  average  case 
of  severe  pelvic  or  appendiceal  peritonitis  has  most  extensive  adhe- 
sions during  and  immediately  after  the  attack  yet  a  few  months  later 
there  may  be  scarcely  any  to  be  discovered  anywhere  in  the  abdomen. 
On  the  other  hand,  every  surgeon  of  experience  knows  that  after 
operations  which  were  performed  for  non-inflammatory  conditions, 
where  every  form  of  traumatism  or  infection  could  be  ruled  out, 
where  no  packings  or  drains  were  used,  where  no  reaction  of  any  kind 
was  observed,  in  short  in  cases  where  the  conditions  were  apparently 
ideal  as  regards  their  avoidance,  very  extensive  adhesions  not  only 
develop  but  persist  in  spite  of  every  effort  to  get  rid  of  them. 

In  general  it  may  be  said  that  the  immediate  formation  of  peritoneal 
adhesions  after  operation  is  in  direct  proportion  to  the  amount  of 
sepsis,  the  raw  areas  left  by  operative  procedures,  the  injury  to  peri- 
toneal surfaces  resulting  from  contact  with  gauze  pads  and  drains, 
the  minor  traumatisms  incident  to  operative  manipulations  and  the 
injury  due  to  chemicals  and  exposure  to  drying.  The  primary  fibrin- 
ous variety  which  form  over  practically  all  injured  peritoneal  surfaces 
immediately  after  an  operation  are  an  essential  part  of  the  repair 
process  which  makes  intra-abdominal  surgery  possible.  In  so  far  as 
they  represent  repair  of  unnecessary  damage  they  are  to  be  avoided, 
but  in  themselves  they  have  little  influence  on  the  outcome  of  the 


PROGNOSIS  OF  THE  OPERATION  ITSELF  63 

operation.  Most  of  these  adhesions  disappear  by  resolution  and  the 
majority  of  those  which  undergo  organization  are  soon  reabsorbed. 
The  trouble  is  that  all  of  them  may  not  be  reabsorbed  and  that  in 
the  present  state  of  our  knowledge  it  is  almost  impossible  to  predict 
which  will  be  permanent  and  which  will  not.  Very  extensive  experi- 
mental w^ork  designed  to  determine  the  laws  governing  their  formation 
and  persistence  has  served  to  emphasize  the  fact  that  results  even 
under  experimental  conditions  are  extremely  variable.  The  literature 
and  experimental  data  has  been  reviewed  by  Richardson^  to  whom  we 
are  indebted  for  many  of  the  references  quoted  below. 

In  estimating  the  possibility  of  troublesome  adhesions  in  the  indi- 
vidual patient  it  is  necessary  to  consider  each  of  the  several  possible 
causes  of  adhesions,  such  as  blood  clots  and  free  blood  in  the  peri- 
toneum, sutures,  ligatures,  etc.,  which  may  be  present  in  the  case  at 
hand. 

Blood  Clots  and  Free  Blood  in  Peritoneum. — The  relation  of  free  blood 
in  the  peritoneal  cavity  to  adhesion  formation  is  a  question  about 
which  a  final  verdict  has  not  yet  been  given.  Penzoldi:^  published,  in 
1876,  the  results  of  a  very  elaborate  experimental  research  into  the 
fate  of  large  amounts  of  blood  in  the  peritoneal  cavity,  showing  that 
it  is  absorbed.  Wegner,^  in  1877,  and  later  Vogel,"^  observed  the  same 
thing  experimentally,  v.  Dembowski,^  in  1888,  reported  the  results 
of  a  large  number  of  carefully  executed  experiments  on  adhesion 
formation  in  the  peritoneal  cavity,  and  concluded  with  reference  to 
blood  clots,  that  they  do  not  provoke  adhesions.  Fromme'^  reported 
a  few  years  ago  the  results  of  very  elaborate  and  painstaking  experi- 
ments on  rabbits  designed  to  test  (1)  the  effect  of  blood  alone,  and 
with  serous  defects  in  the  peritoneal  cavity;  and  (2)  of  infected  blood 
alone,  and  with  serous  defects;  using  for  this  test  pure  cultures  of 
common  bacteria.  He  concluded  that  in  the  vast  majority  of  cases 
neither  blood  alone  nor  with  peritoneal  defects  produces  adhesions. 
Furthermore,  some  of  the  cases  with  infection  added  showed  none, 
although  the  majority  of  these  did  develop  adhesions,  especially  those 
with  raw  peritoneal  surfaces.  Other  investigators  have  reached  the 
same  conclusions.  Flateau'^  leaves  all  blood  in  the  peritoneal  cavity 
in  cases  of  ruptured  extra-uterine  pregnancy  except  that  which  escapes 
as  a  result  of  necessary  operative  manipulations.  He  condemns  all 
efforts  to  remove  it  on  the  ground  that  it  is  impossible  to  get  it  all 
out,  and  that  attempts  to  do  so  only  serve  to  prolong  the  operation 
and  to  injure  the  peritoneum.  Baisch,^  on  the  basis  of  his  experi- 
mental work,  concurs  with  the  view  that  the  peritoneum  is  capable 

1  Studies  on  Peritoneal  Adhesions,  Ann.  Surg.,  1911,  liv,  768-797. 

2  Deutsch.  Arch.  f.  klin.  Med.,  1876,  xviii,  542. 

3  Arch.  f.  klin.  Chir.,  1877,  xx,  51. 

4  Deutsch.  Ztschr.  f.  Chir.,  1902,  Ixiii,  296. 
6  Arch.  f.  klin.  Chir.,  1888,  xxxvii,  745. 

6  Ztschr.  f.  Geburtsh.  u.  Gyniik.,  1907,  lix,  313. 

'Miinchen.  med.  Wchnschr.,  1904,  li,  42. 

8  Beitr.  z.  Geburtsh.  u.  Gynak.,  1905,  ix,  437. 


64  SURGICAL  PROGNOSIS 

of  absorbing  large  amounts  of  blood  without  resulting  adhesions,  if 
intact,  but  finds  that  whenever  a  serosa-free  surface  is  present  it 
always  leads  to  adhesions. 

The  facts  seem  to  be  that  blood  alone  in  the  peritoneal  cavity 
seldom  causes  adhesions,  but  in  the  presence  of  infection  or  peritoneal 
trauma  blood  helps  materially  to  cause  the  production  of  adhesions. 

Sutures  and  Ligatures.— The  relation  of  sutures  and  ligatures  in  the 
peritoneal  cavity  to  adliesion  formation  has  been  carefully  studied 
by  a  number  of  investigators.  Hallwacks,^  as  early  as  1S79,  showed 
that  non-absorbable  sterile  ligatures  in  the  peritoneal  cavity  were  first 
surrounded  by  a  circumscribed  inflammatory  zone  and  finally  covered 
by  a  thin  layer  of  granulation  tissue  which  served  to  encapsulate  the 
sutiu"e  material  which  might  finally  become  disintegrated  through  the 
action  of  the  tissue  juices  and  leukocytes.  Rosenberger,-  Tillmans,^ 
TenBrink,*  Kelterbom^  and  others  later  confirmed  these  observations. 

On  the  other  hand  many  observers  have  noted  firm  adhesions  in  the 
region  of  heavy  silk  ligatures,  and  in  the  presence  of  low-grade  infec- 
tion non-absorbable  sutm-e  material  often  causes  adhesions  to  persist. 

Mechanical  Injury. — All  investigators  agree  that  mechanical  injury 
sufficient  to  destroy  the  endothelium  of  the  peritoneum  results  in 
primary  adhesions  over  the  injured  areas,  but  experimental  as  well  as 
cliaical  results  differ  widely  as  to  the  character  of  injury  necessary  to 
cause  permanent  adhesions.  Pankow/  in  testing  the  relationship  of 
denuded  peritoneal  surfaces  to  adliesion  formation,  was  able  to  produce 
adhesions  in  only  one-half  of  his  cases  by  stripping  the  parietal  peri- 
toneimi  sufficiently  deep  to  cause  multiple  punctiform  hemorrhages. 
Franz  found  no  adhesions  following  aseptic  peritoneal  defects.  Sanger^ 
concluded  from  operations  in  which  portions  of  the  parietal  peritoneiun 
were  resected,  that  one  womid  siuiace  is  sufficient  to  produce  adhe- 
sions, which  inevitably  follow,  and  that  it  is  not  necessary  for  two 
such  areas  to  lie  together  for  their  formation. 

Air  Drying. — Very  elaborate  and  interesting  experiments  have  been 
carried  out  to  ascertain  the  effect  of  air  on  the  peritoneal  endothelium 
and  its  relation  to  adliesion  formation.  The  results  of  these  experi- 
ments as  well  as  clinical  observations  show  that  drying  may  so  injure 
the  peritoneimi  as  to  cause  temporary  adliesions,  but  it  is  doubtful 
whetlier  these  adhesions  are  ever  permanent  except  in  patients  having 
a  special  tendency  toward  the  formation  of  permanent  adhesions. 

Infection. — Adhesions  are  the  most  important  means  of  defense 
against  infection  in  the  peritoneal  cavity  and  at  some  period  during 
each  case  of  intraperitoneal  infection  which  recovers  they  are  practi- 
cally coextensive  with  the  infection.  With  the  elimination  of  the 
infection  these  adhesions  usually  rapidly  disappear  by  resolution  and 

1  Arch.  f.  klin.  Chir.,  1879,  xxiv,  122.  ^  Ibid..  1880,  xxv.  771. 

'  Virchows  Arch.,  1879,  lxx-\-iii,  437. 

*  Ztschr.  f.  Geburtsh.  u.  G\Tiak.,  1898,  xxx^-iii,  276. 

5  Centralbl.  f.  G>-nak.,  1890,  xiv,  913. 

6  Ztschr.  f.  Geburtsh.  u.  Gynjik.,  1907,  lix,  313.  ■  Ibid.,  1884,  xxiv,  1. 


PROGNOSIS  OF  THE  OPERATION  ITSELF  65 

reabsorption  except  in  the  immediate  vicinity  of  persisting  foci  of 
infection.  Thus  during  the  acute  stage  of  a  diffuse  peritonitis  of 
appendicular  origin,  the  fibrinous  adhesions  are  encountered  every- 
where, while  ten  days  later  with  the  subsidence  of  the  diffuse  lesion 
it  is  the  rule  to  find  only  a  narrow  zone  of  organizing  adhesions  walling 
off  a  peri-append icular  abscess.  With  the  drainage  of  the  abscess 
even  these  adhesions  usually  disappear  except  in  those  cases  in  which 
the  appendix  still  retains  some  active  infection.  In  these  cases  the 
zone  of  adhesions  is  soon  limited  to  the  immediate  neighborhood 
of  the  appendix  and  even  these  will  usually  soon  disappear  if  the 
appendix  is  removed.  There  is  still  some  controversy  as  to  whether 
peristalsis  is '  necessary  for  the  freeing  of  adherent  surfaces,  but  it 
seems  probable  that  peritoneal  rest  during  the  acute  stage  and  active 
peristalsis  after  the  acute  stage  has  passed  in  the  means  best  calcu- 
lated to  get  rid  of  adhesions.  In  patients  not  exhibiting  a  special 
tendency  to  adhesion  formation  continuing  irritation  is  undoubtedly 
the  chief  cause  of  persistent  adhesions.  Extensive  adhesions  per- 
sistmg  in  relation  to  a  tube,  ovary,  gall-bladder,  uterus  or  cervical 
stump  usually  signify  that  trouble  stUl  exists  in  these  organs  sufficient 
to  prevent  the  reabsorption  of  the  adhesions. 

Cauterization  by  Heat. — Nothing  illustrates  the  variability  of  factors 
governing  adhesion  formation  better  than  the  results  following  the  use 
of  the  thermocautery  in  the  peritoneal  cavity.  Thus  Spiegelberg  and 
Waldeyer,^  v.  Dembowski,^  Franz^  and  Maslowski^  found  that  it 
produces  adhesions.  Baisch^  and  Kelterborn,^  on  the  other  hand, 
were  unable  to  confirm  this  work.  TenBrink^  produced  adhesions 
with  the  cautery  only  when  infection  was  present.  Kiistner^  reports 
in  detail  a  case  in  which  a  large  ovarian  cyst,  with  many  pelvic  adhe- 
sions, was  removed,  the  actual  cautery  being  used  to  sever  the  adhe- 
sions and  also  the  pedicle  of  the  cyst.  At  a  second  operation  fourteen 
months  later  for  postoperative  hernia  no  adhesions  were  found  where 
the  cautery  had  been  used.  A  possible  explanation  of  these  conflicting 
reports  has  been  given  by  Vogel.  He  found  that  a  superficial  burning 
of  the  peritoneum  generally  gives  rise  to  adhesions,  but  that  none 
occur  after  a  thorough  cauterization  with  the  formation  of  a  thick 
eschar. 

Prevention  of  Adhesions. — The  best  way  to  prevent  adhesions  is  to 
avoid  as  far  as  possible  all  those  causes  which  are  known  to  favor  their 
production.  As  far  as  possible  all  defects  in  the  serosa  should  be 
covered  by  peritoneal  flaps  or  grafts.  However,  in  doing  this  great 
care  must  be  used  to  maintain  normal  relationships,  to  avoid  undue 
tension  and  to  select  proper  suture  material  else  the  attempt  to  prevent 
adhesions  may  -actually  determine  their  formation  under  unfavorable 

1  Virchows  Arch.,  1868,  xliv,  69.  2  Arch.  f.  klin.  Chir.,  1888,  xxxvii,  745. 

3  Ztschr.  f.  Geburtsh  u.  Gynak.,  1902,  xlvii,  64. 

4  Arch.  f.  klin.  Chir.,  1868,  ix,  527. 

6  V.  Vleits:     Ztschr.  f.  Geburtsh.  u.  Gynak.,  1890,  xx,  384. 

^Centralbl.  f.  Gynak.,  1890,  xiv,  913. 

'  Ibid.,  1898,  xxxviii,  276,  *  Ibid.,  189Q,  xiv,  425. 

5 


66  SURGICAL  PROGNOSIS 

circumstances.  Many  other  plans  have  been  devised  for  preventing 
adhesions,  chief  among  which  may  be  mentioned  the  interposition  of 
non-absorbable  or  slowly  absorbable  substances  such  as  silver  foil, 
Cargyle  membrane,  animal,  vegetable  and  mineral  oils  and  even  gases 
and  liquids.  All  of  these  special  methods  have  had  their  advocates 
but  none  have  stood  the  test  of  time  and  most  of  them  have  been 
definitely  proven  to  be  worse  than  useless. 

In  conclusion  it  is  well  to  emphasize  the  fact  that  adhesions  do 
not  always  cause  noteworthy  trouble,  and  that  possibly  the  best  way  to 
avoid  unpleasant  after-results,  such  as  are  usually  ascribed  to  them,  is 
to  make  sure  that  the  operation  actually  cures  the  original  lesion  for 
which  the  patient  is  operated.  Troublesome  adhesions  are  particu- 
larly prone  to  develop  around  persisting  foci  of  low  grade  infection. 
It  is  equally  important  for  the  operator  to  so  arrange  the  position  of 
the  organs  at  the  close  of  the  operation  as  to  insure  normal  relationships 
one  to  another  in  case  adhesions  do  form  subsequently. 

Postoperative  Intestinal  Obstruction. — Intestinal  obstruction  may 
be  either  an  early  or  late  complication  following  abdominal  operations. 

Cases  occurring  immediately  or  within  a  few  days  following  lapa- 
rotomy have  usually  been  classified  under  the  following  heads: 

1.  Septic  ileus  such  as  accompanies  a  septic  peritonitis. 

2.  Paralytic  ileus. 

3.  Mechanical  ileus  usually  due  to  adhesions  and  conditions  result- 
ing therefrom. 

Today  the  term  postoperative  obstruction  is  largely  limited  to  the 
third  group  of  cases  due  to  mechanical  causes  which  may  make  them- 
selves manifest  at  any  time  following  a  laparotomy. 

Cases  of  postoperative  obstruction  coming  on  immediately  or  a 
few  days  after  operation  were  formerly  of  frequent  occurrence  and 
constituted  one  of  the  chief  causes  of  mortality  in  abdominal  surgery. 
In  our  experience  and  pr:)bably  that  of  most  surgeons  in  this  country 
this  form  of  postoperative  ileus  has  almost  entirely  disappeared. 
Beckman  reports  only  3  cases  of  postoperative  obstruction  occurring 
during  convalescence  in  the  course  of  4764  abdominal  operations. 
During  the  past  eleven  years  the  writer  has  had  no  deaths  from  this 
cause  and  only  1  case  requiring  secondary  operation. 

Simplification  of  operative  procedures,  the  application  of  better 
judgment  as  to  w^hat  not  to  do  when  working  in  the  presence  of  recent 
adhesions  and  inflammatory  exudates,  and  the  general  introduction  of 
more  rational  lines  of  postoperative  treatment  are  the  three  chief 
reasons  for  the  lessened  incidence  of  this  complication.  It  seems 
probable  that  the  introduction  of  more  rational  lines  of  postoperative 
treatment  is  the  principal  reason  for  the  reduction.  The  withholding 
of  cathartics  until  normal  bowel  movements  are  obtained  by  enema, 
followed  by  the  withholding  of  food  and  drink  by  mouth  and  the  use 
of  proctoclysis  in  patients  with  suspicious  symptoms  were  important 
steps  in  the  elimination  of  this  complication.  Another  advance  of 
almost  equal  importance  has  been  the  introduction  of  the  prompt  use 


PROGNOSIS  OF  THE  OPERATION  ITSELF  67 

of  the  stomach  tube  whenever  postoperative  cases  became  nauseated 
or  distended. 

As  practically  all  statistics  purporting  to  show  the  frequency  of 
early  postoperative  obstruction  are  based  on  the  results  obtained 
during  the  period  when  early  catharsis  was  supposed  to  be  an  essential 
element  of  after-care,  they  are  entirely  misleading  as  regards  the 
present  time.  Late  cases  of  complete  obstruction  occurring  months 
or  years  after  operation  are  very  rare  considering  the  great  nmnber 
of  patients  now  living  upon  whom  laparotomies  have  been  performed. 
Nevertheless,  every  surgeon  doing  an  active  practice  meets  with  an 
occasional  case  of  complete  obstruction  and  numerous  cases  of  lesser 
grades  of  obstruction  developing  months  or  even  years  after  operation. 

Adhesions  are  the  primary  cause  of  the  great  majority  of  all  cases 
and  adhesions  involving  the  small  bowel  are  far  more  liable  (93  per 
cent. — ^Woolsey)  to  cause  acute  obstruction  than  are  those  involving 
the  large  bowel.  In  a  considerable  percentage  of  cases  it  is  found 
that  the  adhesion  causing  the  obstruction  has  fixed  a  loop  of  small 
intestine  in  a  grossly  abnormal  location  in  the  abdomen.  This  cause 
of  postoperative  obstruction  can  be  largely  avoided  by  using  care 
not  to  disturb  the  normal  relationships  of  the  organs  during  the 
placing  of  or  removal  of  tampons  or  drains. 

As  a  rule,  cases  developing  acute  intestinal  obstruction  after  con- 
valescence from  the  original  operation  should  be  operated  upon  imme- 
diately, because,  even  if  they  do  obtain  relief  from  enemas,  there  is 
almost  no  likelihood  of  the  cause  of  the  obstruction  disappearing,  and 
even  if  the  acute  attack  is  relieved  the  condition  will  almost  certainly 
reappear.  In  any  case  operation  should  not  be  delayed  more  than  a  few 
hours.  The  mortality,  if  operated  during  the  first  twenty-four  hours, 
is  only  nominal,  while  after  twenty-four  hours  it  rises  very  rapidly. 
Naunyn,  in  a  study  of  288  cases  of  acute  obstruction  found  the  mor- 
tality in  cases  operated  the  first  or  second  day  to  average  25  per  cent., 
while  if  operation  was  delayed  to  the  third  day  or  later  the  mortality 
was  from  60  to  65  per  cent. 

The  indications  for  immediate  operation  are  less  definite  in  cases 
occurring  within  a  week  or  ten  days  following  the  primary  operation 
because  secondary  operations  performed  at  this  time  have  a  high 
mortality,  and  if  they  can  be  avoided  the  chances  are  that  the  adhe- 
sions causing  the  obstruction  will  be  ultimately  absorbed. 

Secondary  operations  for  the  relief  of  obstruction  occurring  during 
early  convalescence  have  a  mortality  of  from  25  to  50  per  cent.,  while 
wound  infections  and  ventral  hernias  are  particularly  frequent  in 
those  who  recover.  Such  operations  are  plainly  to  be  avoided  if 
possible,  and  yet  to  procrastinate  when  radical  interference  is  demanded 
is  usually  fatal.  In  our  own  experience  the  following  rule  has  always 
served  to  differentiate  between  the  cases  which  have  demanded  opera- 
tion and  those  which  could  be  cured  by  conservative  treatment.  If 
no  plainly  evident  results  are  obtained  from  two  or  three  enemas 
given  at  intervals  of  two  to  eight  hours,  depending  on  the  urgency  of 


G8  SURGICAL  PROGNOSIS 

the  symptoms,  the  obstruction  is  probably  complete,  and  the  patient 
should  be  operated  before  alarming  symptoms  set  in.  On  the  other 
hand,  if  each  enema  does  yield  a  little  result  in  the  way  of  gas  or 
fecal  matter  it  has  invariably  been  our  experience  that  the  acute  stage 
of  the  obstruction  will  clear  up  without  operation  and  a  recurrence 
of  the  trouble  has  xevy  rarely  been  noted. 

LITERATURE. 

Funk:     Ueber  Ileus  Nach  Laparotomie,  Deutsch.  med.  Wchnschr.,  1905. 

Sonnenburg:     Ueber  Postoperation-Ileus,  Berl.  klin.  Wchnschr.,  1907,  Bd.  i. 

Winternitz :  Ueber  operative  Behandlung  des  postoperativen  Ileus,  Miinchen.  nied. 
Wchnschr.,  1900,  Bd.  ii. 

Martin:     Postoperative  Ileus,  Deutsch.  med.  Wchnschr.,  1907,  Bd.  ii. 

Busch:     Ueber  postoperative  Ileus,  Berlin,  1912. 

Funk:  Acute  Postoperativen  Intestinal  Obstructions,  Jour.  Indiana  State  Med. 
Assn.,  1913,  vi,  433-449. 

McGlannan,  A.:  Intestinal  Obstruction:  A  Study  of  181  Cases,  Tr.  South.  Surg, 
and  Gynec.  Assn.,  1912,  xxv,  26-51. 

Woolsey,  G.:  Postoperative  Intestinal  Obstruction,  Tr.  Am.  Surg.  Assn.,  1910, 
xxviii,  270-298. 

Acute  Dilatation  of  the  Stomach. — Since  the  attention  of  the  pro- 
fession was  forcibly  called  to  this  condition  by  Thompson,^  in  1902, 
this  rare  but  serious  postoperative  complication  has  been  frequently 
recognized  by  all  surgeons.  It  is  also  met  with  after  labor  and  in  many 
non-surgical  diseases  of  the  asthenic  type.  Within  recent  years  the 
more  severe  cases  have  largely  disappeared  from  clinics  where  the 
stomach  tube  is  used  to  treat  postoperative  vomiting.  Equally  bril- 
liant results  are  often  obtained  by  havmg  the  patient  lie  on  his  stomach 
until  the  symptoms  pass  away. 

Postoperative  Ventral  Hemia.^ — Abel-  examined  586  patients  some- 
time after  laparotomy  and  found  that  ventral  hernias  had  developed 
in  from  9  to  20  per  cent,  of  the  scars  depending  upon  whether  the 
incision  had  been  closed  by  approximation  of  the  anatomical  layers 
or  by  through  and  through  sutures.  Harrington^  studied  the  post- 
operative condition  of  236  patients  operated  for  appendicitis;  85 
were  completely  closed  at  the  time  of  operation  and  of  these  3.5  per 
cent,  showed  subsequent  hernia;  88  were  sutured  do^\^l  to  the  drainage 
tube  or  almost  completely  closed  and  of  these  12.5  per  cent,  developed 
hernia;  63  were  treated  by  the  "open  method"  and  20  per  cent,  devel- 
oped hernia.  Since  the  time  when  the  above  figures  were  compiled 
the  results  have  been  greatly  improved,  but  ventral  hernias  still 
constitute  one  of  the  chief  causes  of  unsatisfactory  end-results  after 
laparotomies.  Recent  literature  contains  many  references  to  descrip- 
tions of  technical  procedures  designed  to  prevent  or  cure  this  condi- 
tion but  no  comprehensive  studies  dealing  with  the  frequency  of  this 
complication  mider  modern  conditions. 

The  following  statements  concerning  the  incidence  of  ventral  hernias 

1  Acute  Dilatation  of  the  Stomach,  London,  1902. 
»  Archiv.  f.  Gynekologie,  1898,  Ivi,  956-750. 
'  Quoted  by  Murphy  in  Keen's  Surgery,  iv,  793. 


PROGNOSIS  OF  THE  OPERATION  ITSELF  69 

are  based  very  largely  on  a  personal  study  of  the  kno-^n  end-results 
following  approximately  2000  laparotomies: 

After  abdominal  incisions  of  approved  t^^pe,  closed  in  such  a  manner 
that  the  anatomical  structures  are  held  in  normal  relationship  one 
to  another  while  healing  by  first  intention,  there  is  no  noteworthy 
weakening  of  the  abdominal  wall.  Any  cause  which  interferes  with 
the  union  of  properly  approximated  surfaces  predisposes  to  ventral 
hernia.  Chief  among  these  causes  may  be  mentioned  infection,  early 
excessive  strains  on  the  incision,  drainage,  nerve  injuries  and  obesity. 
In  the  average  clean  case  the  union  at  the  end  of  two  weeks  should  be 
suiBciently  strong  to  withstand  the  strains  of  ordinary  life,  but  from 
four  to  six  weeks  should  elapse  before  hard  manual  labor  is  undertaken. 
In  obese  individuals  and  those  suffering  from  constitutional  defects 
such  as  marked  anemia,  jaundice,  etc.,  due  allowance  should  be 
made  for  delayed  repair  even  though  it  be  by  first  intention.  If  the 
incision  has  been  infected  the  danger  of  subsequent  hernia  may  be 
considerably  reduced  by  insisting  that  no  strain  be  placed  on  the 
wound  for  at  least  ten  weeks  after  it  has  closed. 

Ventral  hernias  following  primary  union  of  undramed  abdominal 
incisions  are  very  rare  and  when  they  do  develop  they  are  almost 
always  the  result  of  abnormal  strams  being  placed  on  the  sutures  soon 
after  the  operation.  Excessive  postoperative  coughing,  especiahy  in 
upper  abdominal  incisions,  has  been  followed  by  ventral  hernia  in  a 
number  of  patients  who  must  certainly  have  escaped  had  it  not  been 
for  the  coughing.  Obese  patients  may  develop  ventral  hernia  with- 
out the  -oresence  of  any  other  demonstrable  cause.  In  these  cases  the 
tissues  which  are  relied  upon  to  give  strength  to  the  incision  are  often 
themselves  weakened  by  fatty  infiltration,  repair  is  slower  than  in 
normal  individuals,  the  line  of  the  incision  must  usually  bear  its 
share  of  the  excessive  weight,  increased  postoperative  intra-abdominal 
tension  is  particularly  common,  and  finally  there  is  the  well-known 
susceptibility  to  infection. 

In  the  great  majority  of  cases  infection  is  the  chief  cause  of  subse- 
quent yielding  of  the  abdominal  scar.  "With  or  without  drainage 
frank  infection  involving  the  suture  lines  of  the  fascial  layers  results 
in  ventral  hernia  in  a  very  large  proportion  of  cases.  In  mildly 
infected  wounds  not  accompanied  by  frank  suppuration  along  the 
fascial  layers  hernias  are  frequently  determined  by  excessive  coughing 
or  other  strains  subjected  to  the  wound  before  firm  union  has  been 
completed. 

Drainage  per  se  predisposes  to  hernia  in  direct  proportion  to  the 
size  of  the  drains  employed.  ^Yhile  drained  cases  are  very  much 
more  likely  to  be  followed  by  ventral  herria  than  are  clean  undrained 
cases,  the  infection  which  necessitates  drainage  rather  than  the  drains 
themseh'es  is  responsible  for  the  resulting  hernias  in  most  instances. 

In  the  writer's  experience,  rectus  and  midline  incisions,  in  which 
drainage  not  over  3  cm.  in  diameter  was  employed  and  in  which 
primary  union  of  the  remainder  of  the  incision  was  obtained,  have 


70  SURGICAL  PROGNOSIS 

yielded  not  over  3  per  cent,  of  hernias  and  these  have  been  of  almost 
no  practical  importance.  On  the  other  hand,  if  in  drainage  cases 
the  closed  portion  of  the  incision  has  suppmrated,  hernias  have  devel- 
oped in  a  considerable  proportion  of  the  scars  depending  upon  the 
extent  and  duration  of  the  suppurative  process.  Incisions  which 
were  packed  open  with  little  or  no  effort  to  obtain  prompt  closure  have 
nearly  all  resulted  in  ventral  hernias. 

Harrington  reported  3.5  per  cent,  of  hernias  developing  in  incisions 
for  appendicitis  which  were  completely  closed  at  the  time  of  opera- 
tion. At  first  sight  this  figure  seems  high  but  it  corresponds  with  our 
o^\^l  observations  in  cases  operated  for  acute  intra-abdominal  condi- 
tions. In  my  experience  ventral  hernias  have  been  particularly  fre- 
quent after  operations  for  acute  appendicitis  in  which  the  conditions 
within  the  abdomen  did  not  demand  drainage  but  in  which  the  tissues 
of  the  abdominal  wall  were  unavoidably  infected  during  the  operation 
causing  a  subsequent  suppuration  in  the  undrained  iacision.  Similarly, 
infection  in  the  main  incision  has  been  much  more  frequent  when 
drainage  was  carried  through  a  lateral  stab  wound  than  when  it  was 
brought  out  through  the  primary  incision.  Because  of  this  fact,  in  the 
cases  examined,  lateral  stab  drains  have  been  a  cause  of  rather  than 
a  means  of  preventing  ventral  hernia.  Data  obtained  from  other 
sources  would  seem  to  confirm  this  view  which  is  contrary  to  that  held 
by  many  surgeons. 

Although  the  theoretical  advantage  of  the  muscle  splitting  incisions 
of  the  INIcBurney  type  are  well  known,  it  is  a  fact  worth  noting  that 
while  the  writer  has  never  used  this  incision  in  operating  for  acute 
appendicitis  and  although  it  has  not  been  commonly  employed  by  other 
surgeons  whose  results  we  have  had  the  opportunity  to  observe, 
nevertheless,  a  very  considerable  proportion  of  the  most  troublesome 
ventral  hernias  which  have  come  under  observation  have  followed 
so-called  IMcBurney  incisions.  This  point  is  of  sufficient  practical 
importance  to  warrant  careful  study  of  much  more  data  before 
expressing  a  definite  opinion.  In  so  far  as  our  ova\  observations  go  the 
muscle-splitting  incisions  of  the  ]\IcBurney  t^^pe  are  definitely  more 
prone  to  give  ventral  hernias  than  are  the  incisions  which  depend  upon 
the  accurate  suturing  of  fascia  layers  for  their  postoperative  strength. 

The  end-results  of  secondary  operations  for  ventral  hernias  depend 
largely  upon  the  size  of  the  hernia.  Small  hernias  are  easily  cured 
while  wide  hernias  have  so  far  been  followed  by  a  large  percentage  of 
recurrences.  Coley^  reports  10  known  recurrences  following  61  oper- 
ations for  ventral  hernia  (16.4  per  cent.)  which  is  about  the  average 
reported  by  other  surgeons.  The  introduction  of  the  imbrication 
method  of  closing  small  and  medium-sized  hernias  has  apparently 
given  better  results  than  the  old  edge-to-edge  approximation  of  the 
anatomic  layers,  and  the  use  of  the  silver  wire  filigree  has  yielded  good 
results  in  many  cases  previously  inoperable. 

•Progressive  Medicine,  June,  1913. 


PROGNOSIS  OF   THE  OPERATION  ITSELF  71 

Cystitis. — Cystitis  is  one  of  the  most  frequent  and  distressing  of 
the  minor  postoperative  complications.  It  is  particularly  frequent 
after  gynecological  operations,  and  after  pan-hysterectomy  for  cancer 
cystitis  is  so  frequent  and  serious  a  complication  as  to  have  a  decided 
bearing  on  the  prognosis  of  the  operation.  Hemorrhoid  and  hernia 
operations  as  well  as  simple  appendectomies  are  also  often  followed 
by  cystitis.  Its  occurrence  after  such  operations  may  mean  that  the 
patient  has  been  relieved  of  one  condition  only  to  be  left  with  a  much 
more  troublesome  and  possibly  even  dangerous  infection  of  the  bladder. 

The  causes  responsible  for  postoperative  cystitis  are  none  too 
well  understood.  Formerly  surgeons  were  agreed  that  infection 
introduced  through  catheterization  was  the  immediate  cause  of  the 
infection.  More  recently  it  has  been  recognized  that  this  simple 
explanation  is  insufficient  and  that  it  is  the  abnormal  condition  of 
the  bladder  necessitating  the  catheterization  which  is  probably  the 
most  important  factor  in  causing  the  cystitis.  The  normal  bladder 
is  not  easily  infected  even  by  catheterization.  On  the  other  hand, 
after  certain  operations,  especially  those  involving  the  immediate 
neighborhood  of  the  bladder,  this  organ  becomes  highly  susceptible  to 
infection  which  may  develop  with  or  without  catheterization. 

In  attempting  to  reduce  the  frequency  of  this  complication  in  our 
own  cases  it  soon  became  apparent  that  extreme  care  used  in  catheter- 
izing  cases  of  postoperative  retention  had  little  effect  on  the  frequency 
of  cystitis.  Likewise  there  was  little  or  no  demonstrable  benefit 
from  the  prophylactic  use  of  urinary  antiseptics  administered  by 
mouth. 

On  the  other  hand,  in  the  writer's  experience  cystitis  as  a  post- 
operative complication  has  been  practically  eliminated  since  adopting 
the  plan,  in  all  cases  of  postoperative  retention,  of  frequent  catheteri- 
zation followed  each  time  by  the  injection  into  the  bladder  of  one 
ounce  of  saturated  boric  acid  solution  which  is  allowed  to  remain 
until  the  next  catheterization.  This  method  of  prophylaxis  is  simple 
and  harmless  and  has  apparently  proved  to  be  of  real  value. 

Injury  to  the  Ureter. — In  4086  major  operations  in  the  gynecological 
service  of  the  Johns  Hopkins  Hospital  studied  by  Sampson,^  there 
were  32  known  instances  of  injury  to  the  ureter  occurring  during 
operation.  A  ureter  was  clamped  sixteen  times;  a  portion  of  the  ureter 
was  intentionally  excised  six  times;  a  ureter  was  incised  three  times,  a 
ureter  was  completely  divided  three  times  and  the  blood  supply  was 
so  interfered  with  as  to  cause  a  subsequent  ureteral  fistula  seven  times. 
The  ureter  was  tied  or  clamped  three  times  in  50  abdominal  hyster- 
ectomies for  carinoma  of  the  cervix;  once  in  26  combined  abdominal 
and  vaginal  hysterectomies  for  carcinoma;  three  times  in  63  vaginal 
hysterectomies  for  carcinoma  of  the  cervix;  four  times  in  516  hystero- 
myomectomies;  twice  in  276  hysterosalpingoophorectomies  for  pelvic 
inflammatory  disease;  once  in  63  repairs  of  vesicovaginal  fistula;  once 

1  Ligation  and  Clamping  of  the  Ureter  as  Complications  of  Surgical  Operations,  Am. 
Med.,  1902,  iv,  693-700. 


72  SURGICAL  PROGNOSIS 

in  100  fixations  of  the  kidney  and  once  in  a  combined  vaginal  and 
abdominal  colpohysterectomy  for  carcinoma  of  the  vagina. 

In  a  series  of  310  intra-abdominal  pelvic  operations  performed  by 
the  writer  the  ureter  was  injured  twice.  Once  in  ligating  a  deep 
pelvic  vessel  a  ureter  was  punctured  by  the  suture  in  such  a  way 
as  to  allow  the  urine  to  escape  into  the  general  peritoneal  cavity  with 
a  fatal  result.  In  the  second  case  a  portion  of  a  ureter  which  was 
adherent  to  an  intraligamentary  cyst  was  excised  along  with  the  cyst. 
In  this  patient  immediate  nephrectomy  was  followed  by  recovery. 
In  two  other  cases  ureteral  fistulfe  developed  following  the  removal 
of  gauze  packs  which  had  been  placed  against  the  exposed  ureter. 

Although  injury  to  the  ureter  is  one  of  the  rare  surgical  accidents, 
it  is  nevertheless  of  sufficient  frequency  to  make  it  one  of  the  most 
important  single  complications  liable  to  be  encountered  in  gyneco- 
logical work. 

Postoperative  fistulse  developing  in  the  presence  of  infection  are 
followed  by  ascending  infection  and  pyelonephrosis  in  a  very  large 
proportion  of  cases. 

Divided  ureters  implanted  into  the  intestine  always  result  in  ascend- 
ing infection  and  the  same  may  be  said  of  the  great  majority  of  cases 
where  the  ureter  is  implanted  into  the  bladder. 

Uretero-ureteral  anastomosis  is  sometimes  successful  but  is  more 
often  followed  by  hydronephrosis  and  infection. 

Permanent  ligation  of  the  ureter  results  in  an  atrophy  of  the  kidney 
without  recognizable  clinical  symptoms  in  the  majority  of  cases, 
although  in  some  cases  ligation  is  followed  by  hydronephrosis. 

Parotitis. — At  the  present  time  parotitis  is  a  rare  postoperative 
complication. 

Stephen  Pagent,  in  investigating  the  causes  in  101  cases,  found  that 
in  50  cases  parotitis  arose  after  disease  or  temporary  derangement  of 
the  generative  organs ;  23  cases  of  parotitis  arose  after  disease  or  injury 
of  the  abdominal  wall,  peritoneum  or  pelvic  cellular  tissue;  18  cases 
arose  after  disease  or  injury  to  alimentary  canal;  10  cases  arose  after 
disease  or  injury  of  the  urinary  tract. 

In  our  experience  it  has  usually  followed  operations  for  Some  form 
of  acute  intraperitoneal  infection.  It  is  an  exceedingly  distressing 
complication  which  may  occasionally  determine  a  fatal  termination 
in  patients  already  handicapped  by  serious  illness. 

Postoperative  Intestinal  Fistulas. — Postoperative  intestinal  fistulse 
occur  most  frequently  after  operations  for  acute  appendicitis.  They 
are  also  met  with  after  operations  for  pelvic  infections  and  after  other 
intra-abdominal  operations  undertaken  for  the  relief  of  long-standing 
infection.  Sometimes  they  follow  leakage  from  the  suture  lines  after 
intestinal  anastomoses. 

Chronic  tubercular  infections  within  the  abdomen  are  very  fre- 
quently accompanied  by  small  fistulse  into  the  intestines  which  may 
not  be  discovered  until  a  fecal  fistula  has  developed. 

The  great  majority  of  fecal  fistulse  close  spontaneously.     Serious 


PROGNOSIS  OF  THE  OPERATION  ITSELF  73 

complications  are  seldom  encountered  unless  the  fistula  be  in  the 
duodenum  or  jejunum  when  the  loss  of  semidigested  food  through  the 
fistula  may  interfere  with  the  nutrition  of  the  patient.  In  appendix 
cases  and  after  pelvic  operations  the  fistulee  usually  close  spontaneously 
in  from  ten  to  fourteen  days.  Fistulse  in  cases  of  tuberculosis  are 
always  serious  but  some  of  them  close  spontaneously.  Those  follow- 
ing anastomosis  operations  usually  spell  failure  although  occasionally 
one  may  close  without  further  operative  interference  if  there  be  no 
obstruction  at  or  distal  to  the  anastomosis.  When  an  ordinary 
fecal  fistula  fails  to  close  spontaneously  the  failure  is  usually  due  to 
some  obstruction  in  the  intestine  distal  to  the  fistula. 

In  the  past  leakage  from  the  intestine  has  often  been  caused  by 
gauze  packs  placed  against  suture  lines,  appendix  stumps  or  weakened 
intestinal  walls.  Others  have  been  due  to  pressure  necrosis  from 
glass  or  stiff  rubber  tubes. 

During  the  past  few  years  the  incidence  of  fecal  fistula  has  been  so 
markedly  lessened  as  to  make  worthless  all  of  the  older  data  con- 
cerning the  frequency  of  this  complication. 

Nerve  Injuries. — ^Injuries  to  important  nerves  often  mar  the  results 
of  otherwise  successful  operations.  Only  extreme  care  and  a  thorough 
knowledge  of  anatomy  will  suffice  to  avoid  these  injuries.  Facial 
paralysis  following  mastoid  operations  and  operations  in  the  upper 
cervical  and  parotid  regions  is  relatively  frequent  and  of  great  impor- 
tance. Injury  to  the  spinal  accessory  is  a  common  complication  of 
operations  in  the  cervical  region.  Abdominal  incisions  should  be 
so  planned  as  to  avoid  injuring  the  nerve  supply  to  the  abdominal 
muscles  as  otherwise  serious  weakness  of  the  abdominal  wall  may 
result.  Injuries  and  operations  on  the  extremities  are  always  liable 
to  be  accompanied  by  serious  nerve  injuries.  Suture  of  the  divided 
nerves  yields  good  results  in  many  cases  but  the  process  of  repair  is 
very  slow  and  the  percentage  of  failures  is  high. 

Musculospiral  paralysis  due  to  the  arm  resting  over  the  edge  of  the 
operating  table  while  the  patient  is  under  the  anesthetic  is  one  of  the 
most  distressing  of  the  avoidable  postoperative  complications.  With 
constant  attention  to  details  this  complication  can  be  avoided,  but 
with  the  least  carelessness  it  may  occur  with  considerable  frequency. 
The  patient,  operated  for  some  minor  disability  and  left  with  a  painful 
crippled  arm  for  six  months  or  a  year  after  the  operation,  is  a  sad 
victim  of  misplaced  confidence. 

Scars. — The  possibility  of  unsightly  scars  must  always  be  borne  in 
mind,  especially  when  operating  on  the  face  and  neck.  Scars  may 
have  little  bearing  on  the  postoperative  result  viewed  from  a  purely 
scientific  standpoint,  but  the  talkative  woman  who  has  been  relieved 
of  a  disfiguring  goiter  and  left  with  a  slight  scar  visible  only,  on  party 
occasions,  is  prone  to  forget  the  goiter  and  dwell  on  the  disfigurement 
caused  by  the  scar. 

Artificial  Menopause. — In  women  who  have  had  both  ovaries 
removed  before  the  period  of  the  natural  menopause,  there  results  an 


74  SURGICAL  PROGNOSIS 

artificial  menopause  characterized  by  phenomena  similar  to  those 
seen  at  the  natural  menopause,  only  often  in  a  peculiarly  exaggerated 
form. 

Gynecologists  still  differ  in  their  opinions  concerning  the  effect  of 
the  removal  of  the  uterus  with  the  preservation  of  one  ovary  on  this 
condition,  but  most  surgeons  have  long  been  convinced  that  the 
preservation  of  an  adequate  amount  of  ovarian  tissue  is  the  essential 
factor  in  avoiding  these  phenomena.  Dickinson/  after  studying  164 
cases,  arrives  at  the  following  conclusions: 

"Conservation  of  the  ovarian  structures  after  hysterectomy  show 
four-fifths  of  the  patients  free  from  marked  disturbance  of  the  surgical 
menopause.  The  results  are  somewhat  better  where  both  ovaries 
remain  than  where  one  is  left  or  resections  are  made. 

"Where  disturbances  do  occur  their  character  is  less  severe  and 
more  gradual  than  after  bilateral  removal  of  the  ovaries.  In  married 
women  conservation  shows  nearly  uniform  persistence  of  sexual 
desire." 

To  preserve  the  functional  activity  of  the  ovary  its  circulation  must 
not  be  impaired.  Removal  of  the  tube  frequently  compromises  the 
blood  supply  and  barring  definite  evidences  of  disease  the  tube  should 
be  preserved  when  the  ovary  is  preserved  in  doing  a  hysterectomy. 

The  disorders  of  the  artificial  menopause  are  flashes  or  flushes  of 
heat,  palpitations,  hysteroneuroses  and  physical  disturbances.  The 
flushes  come  on,  as  a  rule,  within  a  few  weeks  after  operation  and 
persist  for  periods  of  time  varying  from  a  few  months  to  several  ygars. 
Their  intensity  grows  less,  usually,  in  a  few  months.  They  frequently 
appear  even  forty  to  fifty  minutes  while  the  patient  is  awake,  and 
are  sometimes  preceded  by  a  slight  faintness,  chilly  sensations  or 
dizziness.  The  patient  feels  that  she  is  pale  and  that  the  blood  is 
leaving  the  surface  of  the  body.  This  is  followed  by  a  wave  of  heat 
which  rushes  over  the  surface  of  the  body,  particularly  the  face  and 
neck,  causing  burning,  tingling  and  flushing  of  these  parts,  and  this 
is  succeeded  by  sweating.  The  patient  may  complain  of  her  heart 
beating  very  forcibly,  the  thumping  of  which  she  can  hear.  The 
flushes  are  nervous  phenomena,  the  vascular  system  responding  to 
the  same  sort  of  stimulus  which  causes  blushing. 

Palpation  and  tachycardia,  which  may  or  may  not  accompany 
the  flushes  or  may  appear  independently,  are  likewise  due  to  a  disturbed 
nervous  system. 

The  hysteronervous  and  psychic  phenomena  are  those  of  other 
forms  of  neurasthenia,  but  are  frequently  seen  in  women  who  have 
previously  been  free  from  them. 

Many  surgeons  believe  that  the  morbidity  due  to  the  artificial 
menopause  is  not  to  be  compared  to  the  bad  results  following  attempts 
at  conserving  one  or  both  ovaries.  The  viewpoint  of  surgeons 
opposed  to  conserving  the  ovaries  has  been  recently  emphasized  by 
Polak,^  who  found  that  43  women  in  whom  both  ovaries  were  removed 

iTr.  Am.  Gynec.  Soc,  1911,  xxxvi,  324.  2  ibid,  i,  329. 


PROGNOSIS  OF   THE  OPERATION  ITSELF  .    75 

were  completely  relieved  of  all  pelvic  pain  and  symptoms,  only  3 
suffered  from  flushes,  and  only  1  suffered  from  marked  nervous  phe- 
nomena. Of  32  women  in  whom  one  or  both  or  a  part  of  one  ovary 
was  saved  5  had  enlarged  tender  ovaries  which  caused  them  pain; 
3  of  the  32  women  suffered  from  nervous  phenomena  which  could 
hardly  have  been  worse. 

Postoperative  Susceptibility  to  Fatigue  and  Postoperative  Neuroses. 
— Following  the  average  clean  laparotomy  the  histological  processes 
of  repair  are  essentially  completed  by  the  end  of  the  second  week, 
and  by  the  end  of  the  third  week  there  is  seldom  anj^  objectively 
demonstrable  reason  why  the  patient  should  not  return  to  his  usual 
routine  of  daily  work.  As  a  matter  of  fact,  the  patient  is  almost  never 
able  to  do  this.  The  patient  operated  upon  for  some  relatively  minor 
ailment  is  weak  out  of  all  proportion  to  any  objectively  demonstrable 
cause.  There  may  not  have  been  a  degree  of  temperature  nor  any 
noteworthy  acceleration  of  the  pulse,  theie  may  have  been  no  loss 
of  weight  and  he  may  look  the  pictm-e  of  health,  j'et  the  inability  to 
carry  on  sustained  effort  may  be  even  more  pronounced  and  may 
persist  for  a  much  greater  length  of  time  than  after  a  really  serious 
medical  illness  of  approximately  equal  duration.  The  patient  inter- 
prets his  condition,  not  in  terms  of  pain  or  other  phenomena  directly 
referable  to  the  operation  itseff,  but  in  terms  of  weakness.  He  feels 
compelled  to  wait  weeks  or  even  months  to  "recover  his  strength." 

In  the  light  of  our  present  knowledge  this  postoperative  susceptibility 
to  fatigue  can  best  be  explained  as  the  result  of  a  profound  impression 
on  the  central  nervous  system  or  the  central  nervous  system  plus 
associated  organs  controhing  psychic  and  possibly  muscular  activities. 

In  this  connection  it  should  always  be  borne  in  mind  that  a  surgical 
operation  is,  for  possibly  the  majority  of  patients,  a  great  crisis  in 
their  lives.  Fear,  worry,  anxiety  and  physical  suffering  are  super- 
imposed one  upon  another  and  crowded  into  an  interval  of  a  few 
days  or  hours  in  such  a  way  as  to  tax  the  strongest  nervous  system. 
It  is,  therefore,  little  wonder  that  the  strain  leaves  an  impression  on 
the  nervous  and  psychic  centers  of  a  considerable  proportion  of 
patients.  The  phenomena  referable  to  this  strain  usually  disappear 
slowly  but  certain  effects  may  persist  in  the  form  of  more  or  less 
permanent  neuroses. 

Crile  and  his  followers  believe  that  the  phenomena  under  considera- 
tion are  the  result  of  exhaustion  beyond  the  limits  capable  of  prompt 
repair  of  those  organs  whose  function  is  that  of  converting  latent 
energy  into  kinetic  energy  in  response  to  adaptive  stimuli.  They 
also  claim  that  the  changes  incident  to  the  exhaustion  are  demonstrable 
histologically  by  structural  alterations  in  the  cells  of  these  organs,  the 
degree  of  pathological  alteration  being  directly  proportionate  to  the 
degree  of  overstimulation  due  to  noci  impulses.  According  to  them 
the  cells  of  the  central  nervous  system  are  chiefly  affected  but  the 
suprarenals,  liA-er,  thyroid  and  muscles  may  also  be  involved  m  the 
changes  incident  to  the  exliaustion  of  overstimulation.  Whatever  the 
final  verdict  concerning  the  histological  aspects  of  the  subject  may  be. 


76  SURGICAL  PROGNOSIS 

there  is  no  questionmg  the  fact  that  increased  susceptibility  to  fatigue 
is  readily  demonstrable  after  the  majority  of  surgical  operations  and 
after  many  non-operative  traumas,  especially  those  accompanied  by 
considerable  fright. 

In  the  great  majority  of  cases  this  condition  amounts  only  to  a  more 
or  less  prolonged  period  of  weakness;  the  patients  subsequently  stating 
that  following  the  operation  it  took  six  weeks,  six  months  or  even  a 
year,  to  recover  their  strength.  Nevertheless,  in  considering  the 
prognosis  of  an  operation  the  surgeon  must  always  bear  in  mind  the 
possibility  of  producing  a  true  postoperative  neurasthenia  or  even 
hysteria  and  very  rarely  insanity. 

The  postoperative  neuroses  are  not  different  in  kind  from  the  well- 
kno-wTi  traimiatic  neuroses.  It  is  noteworthy,  however,  that  whereas 
the  traumatic  neuroses  have  been  fully  recognized  for  many  years, 
surgeons  have,  for  the  most  part,  failed  to  recognize  the  fact  that 
many  of  the  neuroses  following  operation  were  the  direct  result  of 
the  pain,  fear,  anxiety  and  other  noxious  influences  incident  to  the 
operation  itself,  and  that  the  operation  was  often  the  principal  and 
not  infrequently  the  sole  cause  of  the  trouble,  even  though  there  were 
no  demonstrable  anatomic  defects  resulting  from  the  surgical  manipu- 
lations themselves. 

Not  only  is  it  important  to  avoid  the  so-called  noci-association  before 
and  during  operations,  but  it  is  equally  important  that  following  an 
operation  or  injury  the  patient's  mental  attitude  be  guided  into  proper 
channels.  The  man  or  woman  who  has  received  an  ordinarily  unimpor- 
tant injury  but  who  looks  forward  to  a  substantial  compensation  for 
"permanent  injury  to  the  nervous  system"  is  almost  invariably  placed 
in  a  mental  attitude  which  continues  the  traumatic  neurosis  until  after 
the  litigation  is  ended.  Likewise  the  patient  who  has  undergone  an 
operation  and  later  develops  the  mental  attitude  of  self-pity  for  each 
little  ache  and  pain  is  almost  sure  to  continue  in  a  state  of  more  or  less 
pronounced  "shell-shock."  If,  on  the  other  hand,  the  patient  can  be 
brought  to  think  constantly  of  how  fortunate  he  or  she  is  that  the  opera- 
tion is  passed,  that  no  serious,  life-threatening  conditions  such  as  cancer 
were  found,  and  to  interpret  each  little  ache  and  pain  as  only  a  natural 
step  in  the  convalescence,  from  a  condition  which  might  have  been 
infinitely  worse,  then  in  our  experience  the  recovery  from  the  nervous 
manifestations  is  prompt  and  positive.  We  believe  that  this  question 
of  abnormal  mental  attitude  is  so  important  a  factor  in  most  cases  of 
traumatic  and  postoperative  neurosis  that  the  effort  to  develop  a 
correct  mental  attitude  has  for  years  formed  the  chief  basis  for  our 
therapy  in  these  cases. 

It  is  a  noteworthy  fact  that  patients  operated  for  real  pathological 
conditions,  be  it  a  pelvic  abscess,  a  cancer  of  the  breast,  an  empyema 
of  the  gall-bladder  or  an  acute  appendix,  seldom  suffer  from  postopera- 
tive neurasthenia;  while  the  patient  whose  abdomen  is  explored  without 
positive  findings  is  more  than  likely  to  suffer  from  nervous  symptoms 
greatly  exaggerated  by  the  operation. 


TECHNICAL  EFEICIEXCY. 


By  albert  J.  OCHSNER,  M.D. 

,  The  idea  of  attaining  technical  efficiency  has  invaded  almost  all 
fields  of  human  activity.  In  the  industries  this  has  taken  so  important 
a  place  that  corporations  employ  efficiency  experts  in  order  to  be 
enabled  to  meet  competition. 

In  surgery,  little  attention  has  been  given  to  this  field,  although 
here  and  there  individual  surgeons  have  grasped  the  idea  and  have- 
developed  systems  far  in  ad^'ance  of  others  in  this  direction. 

Several  elements  are.  involved  in  the  development  of  efficiency. 

1.  Concentration. — Concentration  of  attention  and  energy  are  of 
primary  importance.  If  the  surgeon  regularly  concentrates  his  atten- 
tion upon  the  work  before  him,  his  assistants  and  nurses  will  soon 
acqune  the  same  characteristics,  and  an  endless  waste  of  time  can  be 
eliminated. 

2.  Preparation. — If  the  operation  has  been  thoroughly  planned  and 
ever}i:hing  is  in  readiness  not  only  for  the  operation  but  also  for 
possible  emergencies  and  for  the  surgical  dressing,  much  efficiency 
will  result. 

3.  System. — The  surgeon  who  has  observed  a  large  number  of 
capable  surgeons  operate,  can  avoid  a  vast  amount  of  unnecessary 
manipulation  because  he  can  develop  a  system  which  will  eliminate 
everjlhing  useless  in  all  of  the  methods  observed  and  at  the  same  time 
he  can  adopt  all  of  the  points  which  make  for  efficiency. 

4.  Constancy  of  Working  Plan. — By  developing  a  working  plan 
which  is  constantly  in  use  in  a  hospital  all  of  the  persons  involved, 
operator,  assistants,  anesthetist  and  nurses  know  what  will  be  expected 
of  them  and  will  be  ready  to  do  their  part  promptly  and  efficiently, 
while  a  rattle-brained  operator  who  does  the  same  things  in  a  number  of 
different  ways,  according  to  the  whim  that  strikes  him,  cannot  count 
on  efficient  cooperation. 

5.  limited  Number  of  Assistants. — Clinics  in  which  a  large  number 
of  assistants  and  nurses  are  involved  in  each  operation  must  lack 
efficiency  because  ever}i:hing  handled  is  likely  to  pass  through  a 
number  of  hands,  and  at  each  handling  there  is  an  opportunity  for 
loss  of  time,  infection  and  error. 

6.  Instruments. — ^It  is  much  more  likely  to  develop  a  high  degree 
of  efficiency  if  the  surgeon  and  each  assistant  handles  the  instruments 
which  he  uses  rather  than  to  have  them  passed  to  him  by  a  nurse  or 
another  assistant,  because  it  requires  but  one  mental  act  and  one  motion 
for  each  change  of  instruments,  provided  thev  are  always  placed  in  the 

(77) 


78  TECHNICAL  EFFICIENCY 

same  relative  position  when  these  are  not  handed  to  the  surgeon  by  a 
second  person.  On  the  other  hand,  if  they  are  handed  by  a  nurse  or 
an  assistant,  whenever  the  surgeon  decides  upon  the  next  step,  if  the 
assistant  happens  to  have  thought  of  exactly  the  same  step  he  may 
anticipate  the  operator;  if,  however,  the  surgeon  must  call  for  the 
instrument,  or  if  the  wrong  one  is  handed  to  him,  there  is  a  loss  of 
time  and  energy,  and  usually  some  mental  irritation,  all  of  which 
conditions  do  not  make  for  efficiency. 

Automatic  Action. — Everything  that  we  do  really  very  well  we  do 
more  or  less  automatically,  and,  other  things  being  equal,  the  more 
we  can  introduce  this  element  into  surgical  technic  the  greater  will  be 
our  efficiency. 

Arrangement  of  Operating  Room. — Much  can  be  accomplished  to 
increase  efficiency  by  carefully  studying  the  arrangement  in  the 
operating  room.  By  studying  the  motions  required  in  doing  surgical 
work  and  observing  the  distances  to  be  traveled  in  accomplishing  the 
work,  one  can  arrange  the  furniture  and  apparatus  in  the  operating 
room  so  as  to  reduce  to  a  minimum  the  waste  of  energy  required  and 
this  will  of  course  increase  the  efficiency. 


ASEPTIC  AND  ANTISEPTIC  TECHXIC. 


By  albert  J.  OCHSKER,  M.D. 

The  practice  of  antiseptic  surgery  was  based  upon  the  kno\^'ledge 
that  suppuration  and  inflammation  occur  only  in  the  presence  of  micro- 
organisms in  the  tissues  involved  and  upon  the  supposition  that  these 
microorganisms  should  be  destroyed  by  the  introduction  of  some  sub- 
stance or  some  combination  of  substances  which  has  been  demon- 
strated to  possess  the  power  of  destro^-ing  microorganisms  or  to  inliibit 
their  growth  or  their  power  of  reproduction  to  a  sufficient  extent  to 
enable  the  tissues  to  destroy  them.  Aseptic  surgery,  on  the  other 
hand,  attempts  to  accomplish  the  same  result  by  keeping  wounds  free 
from  microorganisms  to  a  sufficient  extent  to  enable  the  tissues  to 
destroy  the  very  small  number  which  may  obtain  entrance  into  the 
wound,  notwithstanding  any  precautions  that  may  be  taken. 

A^Tien  we  come  to  consider  the  practical  details  of  accomplishing 
these  objects,  however,  so  many  conditions  have  a  definite  and  impor- 
tant bearing  upon  the  results  in  wound-healing  that  it  is  quite  worth 
while  to  go  into  details. 

These  will  be  considered  in  an  intensely  practical  way  in  order  to 
give  them  the  position  they  deserve  in  the  planning  of  actual  surgical 
work. 

x\t  the  present  time  aseptic  methods  are  almost  universally  employed 
in  the  treatment  of  wounds  that  are  made  by  the  surgeon  in  tissues 
which  are  not  already  infected.  This  is  proper  because  none  of  the  anti- 
septics can  in  any  way  benefit  the  tissues  of  wounds  which  are  free 
from  infectious  material,  while  undoubtedly  many  of  the  antiseptic 
substances  which  have  been  introduced  into  practice  have  harmful 
effects  upon  the  tissues.  f^' 

It  is  at  the  same  time  possible  to  prevent  the  introduction  of  micro- 
organisms into  these  wounds  to  so  great  an  extent  that  the  slight 
number  which  may  be  introduced  accidentally  can  be  easily  disposed 
of  by  the  natural  action  of  the  tissues,  provided  these  tissues  be  given 
a  fair  chance  to  defend  themselves  against  these  intruders. 

We  must  then  provide  against  the  introduction  by  contact  of  micro- 
organisms into  the  uninfected  wounds.  The  fear  of  infection  from 
microorganisms  in  the  air  has  been  proved  to  be  unfounded.  Exposing 
culture  plates  in  an  operating  room  will  demonstrate  that  the  air 
practically  always  contains  microorganisms,  the  number  varying  with 
the  amount  of  dust  present;  but  even  in  operating  rooms,  in  which  a 
large  number  of  microorganisms  are  present  in  the  air,  infection  of 
wounds  will  not  occur  provided  precautions  are  taken  against  contact 

infection. 

(79) 


80  ASEPTIC  AND  ANTISEPTIC  TECHNIC 

I  recall  some  notable  examples  in  my  personal  observation  which 
may  serve  as  illustrations.  "While  serving  in  the  capacity  of  surgical 
assistant  in  one  of  the  clinics  connected  with  a  medical  college  thirty 
years  ago,  when  this  subject  was  in  its  developmental  stage,  I  had  an 
opportunity  to  observe  the  work  of  two  of  the  members  of  the  hospital 
statt"  who  were  at  the  same  time  members  of  the  surgical  faculty  of  the 
college. 

One  of  these  surgeons  performed  his  operations  in  the  hospital 
operating  room,  which  was  cleaned  and  disinfected  with  the  most 
scrupulous  care.  Everyone  in  the  operating  room  wore  a  sterilized 
gown  and  every  possible  precaution  was  taken  to  prevent  air  and 
contact  injection.  Before  important  operations  the  air  was  sprayed 
at  times  by  means  of  an  atomizer  with  5  per  cent,  carbolic  acid  solution. 
The  conditions,  in  other  words,  were  quite  as  perfect  for  performing 
an  aseptic  or  antiseptic  operation  as  they  are  now  in  our  modern 
hospitals. 

The  other  surgeon  performed  his  operations  in  a  public  amphi- 
theater with  five  hundred  seats,  most  of  which  were  usually  filled  with 
students  and  practitioners.  These  surgical  clinics  were  conducted 
three  afternoons  each  week,  while  on  the  opposite  days  the  same 
amphitheater  was  used  by  the  professor  of  anatomy  in  the  demon- 
strations upon  the  cadaver. 

The  dissecting  room  was  located  in  the  story  above  the  amphi- 
theater, and  many  of  the  students  came  directly  from  their  dissections 
to  the  surgical  clinic  without  stopping  to  change  their  clothing. 

Occasionalh'  the  amphitheater  was  swept  and  dusted.  The  floor  of 
the  operating  pit  and  the  surrounding  woodwork  were  washed  with  5 
per  cent,  carbolic  acid  before  the  operations,  and  everything  that  was 
likely  to  be  touched  by  any  one  connected  with  the  operation  was 
covered  with  sterile  sheets.  During  each  month  more  than  one 
hundred  operations  were  performed  in  this  operating  room.  The 
assistants  and  nurses,  instruments,  ligatures  and  sutures  and  supplies 
for  both  surgeons  were  supplied  by  the  hospital  and  were  identical. 
In  the  one  case  the  wounds  healed  by  primary  intention  almost  without 
exception,  not  even  a  stitch  abscess  being  present;  in  the  other  instance 
absolutely  aseptic  healing  was  practically  unheard  of,  there  being  at 
the  very  best  a  few  stitch  abscesses. 

The  surprising  feature  being  that  all  of  these  infections  occurred  in 
the  practice  of  the  surgeon  whose  work  was  done  in  an  ideally  prepared 
operating  room  while  none  occurred  in  the  dirty  college  clinic  room. 

It  is  needless  to  state  that  when  the  surgeon  who  conducted  the 
public  clinic  performed  his  private  operations  in  the  aseptic  operating 
room  in  the  hospital  on  the  alternate  days  that  the  wounds  made  there 
also  regularly  healed  by  primary  union. 

These  observations  were  most  convincing  of  the  fact  that  there  is 
no  infection  in  surgical  practice  except  contact  infection,  to  which 
should  be  added  infection  from  saliva  thrown  into  the  wound  by 
speaking  while  facing  the  operation  wound. 


ASEPTIC  AND  ANTISEPTIC  TECHNIC  81 

The  observation  described  above  confirmed  a  similar  observation 
I  had  made  in  two  foreign  clinics  in  which  two  gynecological  surgeons 
were  working  in  adjoining  buildings.  One  of  these  operated  in  a  large 
amphitheater  open  to  all  students  and  visitors ;  these  were  not  required 
to  take  any  antiseptic  precautions.  The  second  clinic  could  be  visited 
by  only  a  few  visitors  each  day  and  all  had  to  be  covered  with  sterile 
caps  and  gowns.  The  former  I  visited  daily,  the  latter  rarely,  because 
special  permits  were  difficult  to  obtain;  but  I  visited  the  necropsy 
every  morning,  and  to  my  amazement  I  never  saw  a  cadaver  that  had 
been  operated  in  the  former  clinic  who  had  died  from  peritonitis  during 
a  period  of  two  semesters,  while  the  latter  clinic  furnished  a  con- 
siderable number  of  these  cases,  so  much  so  that  one  morning  when 
the  old  professor  of  pathology  saw  the  professor  of  gynecology  enter 
the  necropsy  while  he  was  personally  making  the  rounds,  greeted  his 
colleague  with  the  enthusiastic  exclamation,  "Ah,  Colleague!  here  we 
again  have  one  of  your  wonderfully  typical  cases  of  peritonitis."  This 
observation  was  made  more  than  a  third  of  a  century  ago  and  the  inter- 
vening years  have  convinced  me  that  the  former  surgeon  did  nothing 
which  could  cause  contact  infection  because  his  attention  was  centered 
upon  essentials  while  the  patients  of  the  second  suffered  because  his 
attention  was  so  thoroughly  filled  with  many  non-essential  details 
that  in  some  way  he  overlooked  some  element  which  resulted  in  contact 
infection. 

There  can  be  no  doubt  but  that  practically  in  every  case  of  infection 
the  microorganisms  determining  the  kind  of  infection  were  placed  in 
the  wound  by  some  object  which  in  turn  had  come  in  contact  with 
infectious  material,  and  that  if  such  conditions  are  established  that  this 
cannot  happen,  that  then  the  wounds  will  remain  aseptic. 

A  most  perfect  system  has  been  developed,  for  example,  by  Sir 
Arbuthnot  Lane  in  connection  with  his  operations  upon  bones.  In 
these  operations  the  following  procedure  is  employed:  (1)  All  instru- 
ments, sponges,  ligatures,  sutures  and  dressings  are  prepared  so  that 
they  are  absolutely  sterile.  The  surgeon's  hands  are  covered  with 
sterile  rubber  gloves.  The  skin  is  rendered  sterile  so  far  as  this  is 
possible.  After  the  primary  incision  through  the  skin,  its  edges  are 
covered  with  sterile  towels  fastened  in  place  by  means  of  suitable  clamps 
in  order  to  prevent  infection  of  the  wound  by  transfering  staphylococci 
which  had  not  been  removed  from  the  skin  at  the  time  of  its  disinfec- 
tion. The  knife  with  which  the  skin  incision  was  made  is  then  laid 
aside,  and  from  this  time  on  no  one  except  the  operator  touches 
either  instruments  or  wound  except  with  instruments  or  sterile 
sponges. 

In  this  manner  infection  can  be  prevented  with  certainty.  There 
is  no  reason  why  most  of  the  other  operations  could  not  be  done 
according  to  this  perfect  system  although  this  is  not  necessary  in  most 
cases  because  primary  healing  of  wounds  occurs  regularly  if  every  one 
connected  with  the  operation  is  surgically  clean.  It  is,  however,  far 
better  to  err  on  the  safe  side  than  to  expose  the  patient  to  even  a  slight 

VOL.  I 6 


82  ASEPTIC  AND  ANTISEPTIC  TECHNIC 

infection  by  overlooking  any  detail.    The  following  bacteria  give  rise 
to  infection  of  wounds: 

1.  The  pyogenic  cocci. 

Staphylococcus  pyogenes  aureus. 
Staphylococcus  pyogenes  citreus. 
Staphylococcus  epidermidis  albus. 

2.  Streptococcus  pyogenes. 
Streptococcus  hemolyticus. 

3.  Bacillus  coli  communis. 

4.  Bacillus  pyoc^-aneus,  produces  bluish  green  pus. 

5.  Pneumococci. 

Other  bacteria  occasionally  found  in  suppurating  wounds. 

Bacillus  typhosus. 

Micrococcus  tetragenus. 

Bacillus  diphtherise;  Klebs-Loeffler  bacillus. 

Gonococci. 

Bacillus  of  tetanus. 

Gas  Gangrene: 

B.  aerogenes  capsulatus;  B.  welchii. 
Vibrion  Septique. 

Bacillus  edematicus;  bacillus  of  malignant  edema. 

Of  these  the  Staphylococcus  aureus  and  albus  are  the  most  common 
and  at  the  same  time  the  least  harmful;  the  latter  of  these  is  almost 
universally  found  in  healthy  skin,  frequently  located  too  deeply  to  be 
reached  and  destroyed  by  the  antiseptics  commonly  in  use  for  disin- 
fecting the  field  of  operation.  One  is  consequently  likely  to  carry 
some  of  these  bacteria  into  the  wound  from  the  exposed  w^ound  edges 
unless  the  wound  itself  is  protected  by  fastening  aseptic  towels  along 
the  skin  edge  of  the  wound  before  manipulating  the  deeper  tissues. 

As  a  matter  of  fact,  wound  infection  during  the  operation  is  almost 
always  due  to  the  fact  that  some  one  person  connected  with  the 
handling  of  the  wound  or  some  of  the  articles  coming  in  contact  with 
it  does  not  give  his  undivided  attention  to  the  M'Ork  in  hand.  An 
excellent  illustration  to  prove  this  theory  can  be  found  in  the  fact 
that  whenever  some  new  method  is  on  trial  at  any  hospital  so  that 
the  interest  and  attention  of  the  entire  staff  is  centered  upon  the  details 
of  the  operations,  one  is  sure  to  find  an  absence  of  infection,  while 
slight  infections  will  again  occur  after  the  interest  has  worn  off. 

The  tissues,  are,  however,  capable  of  disposing  of  a  considerable 
number  of  microorganisms,  providing  favorable  conditions  are  estab- 
lished while  under  unfavorable  conditions  the  same  number  of 
microorganisms  will  give  rise  to  stitch  abscesses  or  more  serious 
complications. 

The  conditions  which  favor  infection  due  to  a  number  of  micro- 
organisms AA'hich  would  not  ordinarily  cause  trouble  are:  (1)  the 
presence  of  dead  space;  (2)  blood  clots;  (3)  traumatism  of  tissues; 
(4)  drawing  of  sutures  too  tightly;  (5)  grasping  large  portions  of  tissues 
at  bleeding  points  and  tying  ligatures  around  these  too  tightly;  (6) 


TECHNIC  OF  ASBPflC  OPS  RAT  ION  §3 

tissues  poorly  supplied  with  blood;  (7)  bandages  applied  too  tightly 
interfering  with  circulation;  (8)  ragged  edges  of  wounds;  (9)  carelessly 
placed  drainage  tubes  or  gauze  tampons  interfering  with  the  circulation; 
(10)  badly  planned  skin  flaps. 

Ordinarily  portions  of  the  body  which  are  especially  well  supplied 
with  blood  show  great  resistance  against  infection.  Among  these  we 
may  enumerate  the  tissues  of  the  face,  especially  the  lips  and  cheeks 
and  the  tongue.  The  peritoneum  is  very  resistant  to  infection;  this 
is  also  true  of  the  mucous  membranes.  Whenever  there  is  accumu- 
lation in  a  cavity  lined  with  mucous  membrane  such  as  the  urinary 
bladder,  the  pelvis  of  the  kidney  or  the  gall-bladder,  the  mucous  mem- 
brane becomes  infected.  This  is  also  true  of  the  serous  membranes 
of  the  joints.  Willems  has  shown  that  if  open  infected  joints  are 
moved  actively  or  passively  every  two  hours,  the  synovial  membrane 
will  recover  because  this  will  prevent  an  accumulation  of  septic  fluid; 
on  the  other  hand,  if  the  same  joint  is  held  quiet  so  that  the  fluid 
can  accumulate  there  will  be  a  destructive  inflammation. 

Medullary  tissue  of  the  bone  is  very  susceptible  to  infection.  This 
is  also  true  of  loose  connective  and  adipose  tissue. 

The  condition  of  the  patient  affects  the  susceptibility  to  infection. 
The  following  classes  of  patients  lack  resistance : 

1.  Patients  exhausted  from  fatigue  or  exposure  to  cold  and  wet. 

2.  Diabetics  and  nephritics. 

3.  Those  weakened  from  disease. 

4.  Those  weakened  from  intemperance. 

5.  Those  weakened  from  extreme  old  age. 

TECHNIC  OF  ASEPTIC  OPERATION. 

In  my  practice  aseptic  surgery  was  substituted  for  antiseptic  surgery 
in  the  year  1888  as  a  result  of  the  following  observation: 

On  the  same  day  my  chief.  Professor  Charles  T.  Parkes,  operated 
upon  a  number  of  patients,  among  them  tkree  in  whom  he  performed 
abdominal  sections  and  one  in  whom  he  made  a  complete  removal 
of  the  breast.  As  chief  of  his  clinic  I  had  superintended  all  of  the 
antiseptic  preparations  and  directed  every  detail,  so  far  as  handling  of 
instruments,  sponges,  sutures,  ligatures  and  antiseptic  solutions  were 
concerned. 

The  abdominal  wounds  healed  without  a  drop  of  pus  while  the 
breast  wound  showed  a  considerable  amount  of  irritation,  which, 
however,  subsided  shortly.  This  difference  in  the  action  of  w^ounds 
made  under  the  same  careful  supervision  attracted  my  attention 
and  resulted  in  a  careful  review  of  each  step  of  the  operations,  and 
this  resulted  in  the  discovery  that  the  only  difference  in  the  methods 
applied  consisted  in  the  fact  that  the  breast  wound  had  been  carefully 
irrigated  with  a  solution  of  corrosive  sublimate,  which  could,  of  course, 
not  be  applied  to  the  abdominal  wounds. 

A  further  examination  of  previously  operated  cases  showed  that  in 


84  ASEPTIC  AND  ANTISEPTIC   TECHNIC 

a  very  Ijirj^c  iiuinbrr  of  abdominal  sections  we  liad  experienced  no 
infections,  all  wounds  ha\ing  healed  in  an  absolutely  aseptic  manner, 
while  in  the  other  wounds  we  had  obser\ed  some  disturbance  in  a  few 
cases. 

Abandoning  the  use  of  antiseptic  material  in  all  clean  wounds  the 
healing  immediately  became  uniformly  perfect.  We  continued  the 
use  of  antiseptics  in  presumably  infected  wounds,  probably  to  the 
detriment  of  the  patient,  because  as  we  have  abandoned  this  practice, 
our  results  became  more  and  more  satisfactory. 

Our  present  method  of  treating  infected  wounds  is  fully  discussed 
in  the  section  on  ^Military  Surgery,  so  it  need  not  be  repeated  here; 
suffice  it  to  say  that  before  the  war  for  a  number  of  years  our  faith  in 
the  value  of  antiseptic  substances  had  dwindled  down  to  a  kind  of 
superstitious  belief  that  there  is  some  virtue  in  tincture  of  iodin  which 
we  apply  in  the  preparation  of  the  skin  in  the  field  of  operation  and  in 
the  treatment  of  compound  fractures.  Dakin's  solution  and  dichlora- 
mine-T  we  have  adopted  during  the  war.  The  application  of  these 
antiseptic  substances  have  been  described  elsewhere  in  this  work. 

Preparation  of  Hands. — The  first  important  point  to  be  borne  in 
mind  regarding  the  preparation  of  the  hands  of  surgeon,  assistant  and 
nurse  refers  to  general  cleanliness. 

The  hands  should  be  kept  aw^ay  from  unclean  materials.  A  surgeon 
who  is  careless  about  handling  unclean  things  is  much  more  likely  to 
be  a  carrier  of  microorganisms  than  one  who  is  habitually  clean. 

Again,  it  is  important  to  keep  one's  hands  covered  with  smooth 
non-irritated  skin  which  will  shed  dirt  more  easily  than  a  roughened 
skin.  If  any  particular  substance  causes  an  irritation  of  the  surgeon's 
skin  that  substance  should  be  discarded  permanently,  because  of  all 
the  substances  in  use  there  is  not  a  single  one  that  is  indispensable. 
This  can  be  easily  proved  by  the  fact  that  if  a  surgeon  washes  his 
hands  carefully  with  soap  and  sterile  water  and  does  not  use  a  single 
one  of  the  many  antiseptic  substances  that  haxe  been  lauded,  his 
wounds  will  heal  without  infection,  provided  he  eliminates  all  other 
sources  of  contact  infection. 

We  have  pro\'ed  this  fact  in  a  large  number  of  consecutive  cases. 

Still  almost  every  surgeon  has  some  special  antiseptic  lotion  which 
he  has  used  for  a  long  time  and  in  w^hich  he  has  a  kind  of  faith  akin  to 
superstition,  and  whose  systematic  use  gives  him  a  feeling  that  he  has 
done  his  utmost,  a  kind  of  virtuous  feeling.  So  long  as  the  substance 
is  quite  harmless  it  seems  entirely  proper  to  continue  its  use  indefinitely. 

It  is  certainly  important  that  the  surgeon  develop  an  antiseptic 
conscience,  and  it  is  quite  important  to  develop  a  degree  of  enthusiasm 
upon  this  subject  in  everyone  connected  with  making  of  wounds  and 
caring  for  them,  and  it  seems  necessary  to  have  some  superstition  or 
other  to  maintain  the  necessary  attention,  concentration  and  enthu- 
siasm. 

The  important  points  in  rendering  the  hands  aseptic  consists  in 
careful  washing,  preferably  first  in  a  deep  basin  filled  with  warm  water, 


TECH  NIC  OF  ASEPTIC  OPERATION  85 

with  the  use  of  a  soft  cloth  and  an  abundance  of  green  soap.  We  have 
found  that  the  skin  becomes  clean  much  more  rapidly  when  the  hands 
are  scrubbed  in  this  manner  under  water  than  when  this  is  done  under 
the  stream  of  a  faucet. 

After  the  hands  have  been  thoroughly  washed  in  this  manner  the 
nails  are  cleaned  with  a  blunt-pointed  instrument  and  then  these  are 
brushed  thoroughly  with  a  soft  brush  under  water.  The  forearms 
should  be  washed  to  a  point  above  the  elbows  in  the  same  manner. 
The  forearms  and  hands  are  then  washed  under  a  stream  of  sterile 
water,  in  order  to  wash  away  the  soap.  After  this  has  been  done  it 
does  not  matter  what  further  steps  are  taken  so  long  as  the  substance 
used  does  not  harm  the  skin.  Alcohol  is  probably  as  desirable  as  any 
substance,  because  it  dissolves  any  fatty  substance  which  may  not 
have  been  dissolved  by  the  soap.  A  solution  of  1  to  2000  of  bichloride 
of  mercury  in  water  may  be  employed  safely  unless  the  skin  is  sensitive 
to  this  solution,  which  is  the  case  only  very  rarely.  A  |  per  cent,  of 
formalin  in  water  may  be  used,  but  this  is  exceedingly  irritating  to 
the  skin  in  many  cases. 

It  is  important  that  the  hands  be  washed  thoroughly.  Of  course, 
an  active  person  can  clean  his  hands  as  thoroughly  in  one-tenth  of  the 
time  that  it  will  require  a  phlegmatic,  slow  moving  person  to  accom- 
plish the  same  end,  but  it  may  be  well,  in  a  surgical  clinic,  to  have  a 
regular  time  of  at  least  five  minutes  to  be  devoted  to  preparing  the 
hands  before  operations.  During  the  time  consumed  in  doing  this  the 
person's  attention  should  be  directed  upon  the  result  to  be  accom- 
plished. Too  often  too  little  attention  is  given  to  this,  and  the  matter 
of  preparing  the  hands  proceeds  as  a  kind  of  ceremony  instead  of  making 
it  an  important  matter  of  business. 

In  case  the  surgeon's  hands  become  rough  or  irritated  it  is  practically 
always  possible  to  determine  the  cause  of  this  irritation.  It  is  usually 
best,  under  this  condition,  to  have  the  surgeon  take  a  vacation  from 
his  work  in  order  to  permit  the  skin  to  become  quite  normal.  Upon 
resuming  his  work  he  should  use  only  soap  and  sterile  water  for  a 
number  of  days.  Then  if  the  skin  shows  irritation  he  should  discard 
the  use  of  the  kind  of  soap  he  is  using  and  should  use  only  pure  castile 
soap,  which  is  made  of  vegetable  fats,  such  as  olive  oil,  and  which 
practically  never  causes  irritation. 

If  the  soap  and  water  do  not  cause  any  irritation  of  the  skin  he  should 
use  only  one  other  substance  for  a  period  of  a  month,  preferably  grain 
alcohol.  If  this  causes  irritation  it  should  be  discarded,  if  not  any 
other  substance  desired  may  be  added  for  the  next  month.  In  this 
manner  the  irritating  substance  can  be  readily  discovered  and  none  of 
these  substances  are  necessary  and  may  be  discarded  without  causing 
any  harm. 

It  is  well  to  bear  in  mind  that  the  denatured  alcohol  in  the  market 
at  the  present  time  may  contain  some  irritating  substance  which  has 
been  introduced  for  the  purpose  of  changing  pure  alcohol  into  the 
denatured  product. 


86  ASEPTIC  AND  ANTISEPTIC  TECHNIC 

The  most  common  of  these  substances  are  formaldehyde  and  some 
of  the  coal-tar  products.  Camphor  is  the  least  irritating  substance, 
which  is  in  common  use  for  the  purpose  of  producing  denatured  alcohol. 

Rubber  Gloves. — It  is  important  to  disinfect  the  hands  with  exactly 
the  same  care  whether  or  not  rubber  gloves  are  used  because  a  tear 
may  occur  in  the  glove  or  the  necessity  may  arise  for  the  removal  of 
the  glove  during  the  operation,  in  order  to  increase  the  acute  sense  of 
touch,  and  in  either  case,  if  the  hands  were  not  absolutely  clean,  an 
infection  might  result. 

Ordinarily  an  operation  can  be  performed  nearly  as  rapidly  and  as 
well  if  the  surgeon's  hands  are  covered  with  gloves,  and  as  these  can 
be  thoroughly  disinfected  by  boiling,  they  are,  of  course,  readily  ren- 
dered absolutely  sterile. 

There  is  an  advantage  in  the  use  of  rubber  gloves  which  is  not  fully 
appreciated.  The  surgeon  is  much  more  likely  to  tie  his  ligatures  and 
sutures  tightly  enough  to  cause  pressure  necrosis,  working  with  bare 
fingers  because  the  gloves  cause  the  ligature  to  slip  while  tying,  giving 
the  patient  the  additional  protection  against  too  tight  sutures  and 
ligatures. 

It  is  of  special  importance  always  to  wear  gloves  in  operating  upon 
patients  with  infected  wounds  and  in  dressing  infected  wounds. 

In  the  latter  case  it  is  well,  even  if  gloves  are  being  worn,  to  handle 
all  infected  substances  with  forceps,  because  it  establishes  the  habit 
of  keeping  one  s  hands  out  of  unclean  substances,  and  it  is  specially 
important  to  have  the  assistants  and  nurses  to  become  habitually 
clean. 

Everyone  should  habitually  remain  clean  before,  during  and  after 
operations  and  dressings  and  at  all  other  times,  and  when  accidentally 
the  hands  are  soiled,  they  should  be  rendered  surgically  clean  at  once 
during  operations  or  dressings,  and  as  nearly  as  possible  so  at  all 
other  times. 

It  has  been  proved,  by  means  of  a  long  and  carefully  carried  out 
series  of  experiments  by  Sprengel,  that  sterile  gloves  on  the  surgeon's 
hands  which  have  come  in  contact  with  pus  can  be  rendered  sterile 
again  by  simple  washing  with  hot  water  while  still  on  the  hands  of 
the  surgeon.  The  knowledge  of  this  fact  may  serve  to  save  time, 
for  the  patient  occasionally,  when  a  few  minutes  wasted,  may  be  of 
importance,  but,  as  a  rule,  it  is  such  a  simple  matter  to  change  the 
soiled  gloves  for  clean  ones  that  this  plan  should  be  preferred. 

Disinfection  of  Skin  Preliminary  to  Operation. — Before  every  opera- 
tion if  his  condition  permits  it  is  well  to  give  the  patient  a  warm 
tub  bath,  using  a  good  quality  of  soap  and  a  large  soft  wash  cloth 
made  out  of  Turkish  towelling,  because  in  this  way  the  loose  epi- 
dermis and  the  excretions  from  the  sebaceous  glands  of  the  skin  can 
be  removed. 

Two  precautions  should  be  taken,  however:  (1)  the  bath  tub  should 
be  thoroughly  scrubbed  with  soap  or  some  cleaning  powder  and  hot 
water  and  then  with  some  disinfectant,  preferably  with  I  per  cent. 


TECHNIC  OF  ASEPTIC  OPERATION  87 

solution  of  formalin  in  water,  because  if  this  or  some  similar  plan  is 
not  carried  out  bath  tubs  are  likely  to  become  a  source  of  infection. 
As  a  further  precaution  the  nurse  who  prepares  the  bath  should  be 
instructed  invariably  to  run  boiling  w^ater  into  the  tub  until  a  sufficient 
amount  has  accumulated  approximately  to  give  the  bath  a  proper  tem- 
perature after  cold  water  has  been  added.  The  hot  water  should  remain 
in  contact  with  the  tub  for  several  minutes  before  the  cold  water  is 
added. 

A  second  precaution  should  be  borne  in  mind,  namely,  that  it  is  not 
safe  for  patients  who  are  accustomed  to  wearing  woollen  undergar- 
ments and  woollen  night  garments  to  be  placed  in  what  in  some 
stupidly  conducted  institutions  are  known  as  regulation  sterile  garments 
for  surgical  cases.  The  patient  should  be  placed  in  clean  underclothing 
of  the  type  to  which  he  has  been  accustomed;  these  need  simply  be 
freshly  laundried,  but  need  not  be  surgical  aseptic. 

Many  so-called  ether  pneumonias  undoubtedly  result  from  neglect- 
ing this  precaution  or  from  failing  to  protect  the  patient  properly  when 
transported  to  or  from  operating  rooms  and  during  the  time  taken  to 
perform  the  operation. 

The  day  before  the  operation  it  is  well  to  wash  the  field  of  operation 
and  a  large  area  surrounding  the  field  with  soap  and  warm  water, 
preferably  using  a  large  piece  of  sterile  gauze  as  a  wash  cloth.  It  is 
usually  well  to  shave  this  entire  surface  at  the  same  time  and  then  to 
wash  it  with  alcohol  and  to  apply  a  sterile  dressing  in  a  manner  to 
prevent  the  patient  from  touching  the  surface. 

This  can  also  be  postponed  until  the  patient  is  taken  to  the  operating 
room.  In  this  case,  however,  it  is  better  to  wash  the  entire  surface  with 
benzine  first,  then  to  dry  it  perfectly,  permitting  all  of  the  benzine  to 
evaporate,  then  to  wash  with  alcohol  and  then  to  apply  a  mixture  of 
tincture  of  iodin,  U.  S.  P.,  and  grain  alcohol  in  equal  parts  to  the  sur- 
face, which  should  be  permitted  to  dry  before  the  operation  is  begun. 

Another  simpler  method  which  has  given  equally  satisfactory  results 
consists  in  simply  washing  the  field  of  operation  with  soap  and  warm 
water  immediately  before  the  patient  is  taken  to  the  operating  room 
and  then  washing  the  field  of  operation  and  the  surrounding  areas  with 
benzine  very  carefully,  and  drying  the  surface  in  order  to  prevent  irri- 
tation from  the  benzine,  and  then  to  paint  the  entire  surface  with  the 
tincture  of  iodin  and  alcohol  mixture  described  above.  There  is  some 
danger  of  blistering  of  the  skin  especially  if  the  second  method  described 
has  been  used,  but  if  one  is  careful  to  dry  the  surface  and  to  prevent  the 
benzine  from  running  into  any  creases  of  the  skin,  or  to  moisten  the 
sheet  underneath  the  patient,  there  is  little  danger  from  this  source. 

We  have,  however,  abandoned  the  use  of  benzine  and  soap  and  water 
at  the  same  time,  and  have  simply,  of  late,  in  cases  which  for  any 
reason  could  not  receive  any  preliminary  preparation  on  the  day  pre- 
ceding the  operation,  washed  the  surface  with  benzine,  then  shaved  the 
surface  dry,  then  again  washed  it  with  benzine  and  then  we  have 
applied  the  tincture  of  iodin  and  alcohol  mixture  immediately  before 
beginning  the  operation. 


88  ASEPTIC  AND  ANTISEPTIC   TECHNIC 

Disinfection  of  Instruments.— All  instruments  after  being  used 
should  be  carefully  washed  with  a  brusli  in  lukewarm  water  and  soap. 
It  is  best  not  to  use  cold  water,  because  this  is  likely  to  roughen  the 
nurses'  hands,  neither  should  hot  water  be  used,  because  this  will 
coagulate  the  blood  on  the  instruments  and  will  make  the  washing  more 
difficult. 

Instruments  should  never  be  permitted  to  stand  in  water,  because 
this  causes  rusting. 

After  washing  the  instruments  they  should  be  boiled  for  one-half 
hour  in  water  to  which  half  an  ounce  of  bicarbonate  of  soda  in  the  form 
of  ordinary  baking  soda  has  been  added  to  the  gallon  of  water.  This 
will  prevent  rusting.  They  should  })e  dried  out  of  the  hot  water  and 
placed  in  a  case  protected  from  dust.  Before  using  these  instruments 
again  they  should  be  boiled  again  in  the  same  alkahne  solution  for 
two  to  five  minutes. 

Knives  and  scissors  should  be  washed  with  special  care  then  carefully 
wiped  with  95  per  cent,  alcohol  and  then  boiled  for  two  minutes. 
Long-continued  boiling  oxidizes  the  sharp  edge  of  the  instruments. 
The  precaution  should  be  taken  never  to  lay  down  soiled  knives  or 
scissors  without  having  wiped  them  clean  with  a  moist,  gauze  sponge. 
This  can  be  done  without  loss  of  time  during  operation.  Instruments 
will  be  im])ro\ed  if  rubbed  with  liquid  paraffin  when  put  away. 

Preparation  of  an  Operating  Room. — Ideal  temperature  is  80°  F. 
Close  all  windows  and  keep  closed  during  operation.  Disinfect 
floors,  tables,  stands,  etc.,  with  phenol,  solution  of  5  per  cent.,  or 
formaldehyde  solution  |  per  cent.  Dust  carefully  electric  lights  and 
doors  with  moist  cloth.  Cover  radiators  with  sheets.  Place  sterile 
scrub  basins,  soap,  brushes  and  nail  cleaner  in  scrub  stands.  Bring 
in  all  necessary  supplies,  such  as  linen,  solutions,  etc.,  to  be  used  during 
day's  operation. 

After-care  of  Operating  Room. — Ventilate  well  by  opening  all  windows 
Remove  all  supplies.  Wash  all  stands,  tables,  windowsills,  etc.,  with 
soap  and  water,  to  which  ammonia  has  been  added.  The  floor  is 
mopped  with  an  antiseptic  solution  after  scrubbing  with  soap  and 
water. 

Instruments. — Wash  in  lukewarm  water,  as  hot  water  coagulates 
blood.  All  instruments,  with  the  exception  of  those  having  cutting 
edges,  should  sterilize  at  least  twenty  minutes.  Needles  and  scissors 
are  sterilized  five  minutes  only,  to  prevent  cutting  edge  from  becoming 
dull.  To  prevent  instruments  from  rusting  and  also  to  soften  water 
add  sodium  bicarbonate,  1  per  cent.  Instruments  from  septic  oper- 
ations must  be  taken  care  of  separately.  Use  distilled  water  for 
sterilizing  instruments  whenever  possible. 

Disinfection  of  Catheters. — Rubber  catheters  to  be  boiled  for  ten 
minutes  only.  Filiform  bougies,  silk  catheters  and  hard-rubber  cath- 
eters are  washed  thoroughly  with  green  soap  and  then  with  a  saturated 
boric  acid  solution,  then  suspended  in  tall  glass  jars  in  the  fumes  of 
formaldehyde,  produced  by  pouring  formaline  upon  cotton  placed  in 


TECHNIC  OF  ASEPTIC  OPERATION  89 

the  bottom  of  the  jars.  Ordinary  catheters  (rubber)  can  be  preserved 
dry  or  suspended  in  the  same  manner. 

Directions  for  Preparing  Catgut. — Unchromicized  Catgut. — (a)  Keep 
in  ether  in  a  tightly  stoppered  bottle  for  thirty  days.  Shake  con- 
tainer daily.    Change  the  ether  at  the  end  of  the  first  fifteen  days. 

(h)  Keep  in  the  following  solution  for  one  month,  transferring  to 
another  jar.  Alcohol,  95  per  cent.,  1  ounce;  bichloride  of  mercury, 
1  grain.    At  the  end  of  thirty  days  transfer  to  alcohol,  95  per  cent. 

ic)  Storage  Solution. — Iodized  solution.  Can  be  kept  in  this  solution 
indefinitely.  Iodoform  powder,  1  ounce;  ether,  5  ounces;  alcohol, 
14  ounces.  As  solution  evaporates  add  ether  until  all  iodoform  powder 
at  the  bottom  of  the  jar  has  been  dissolved. 

Chromicized  Catgut. — In  ether  for  thirty  days,  changing  at  the  end 
of  the  fifteenth  day.    Shake  container  daily. 

Solution  A. 

(a)  To  mix  chromic  acid  solution  for  catgut:  Chromic  acid,  one 
part;  distilled  water,  five  parts,  dissolve  carefully. 

Solution  B. 

(b)  Take  solution  A,  one  part;  glycerin,  sterile,  five  parts. 
Note. — Pour  solution  A  into  solution  B,   slowly  stirring  all  the 

time. 

(c)  Take  solution  B  and  soak  catgut  from  twenty-four  to  thirty-six 
hours-,  according  to  resistance  desired.  Twenty-four  hours  resist  ab- 
sorption for  seven  to  fifteen  days.  Thirty-six  hours  resist  absorption 
for  fifteen  to   twenty-five   days. 

(d)  Take  catgut  out  of  solution  B,  rinse  quickly  in  sterile  water  to 
free  from  the  chromic  acid  solution.  Stretch  and  rub  quickly  with  a 
hard,  sterile  towel.  "Wind  on  glass  rods  or  slides  and  preserve  in  the 
following  for  thirty  days:  carbolic  solution,  95  per  cent.,  one  part; 
glycerin  (sterile),  five  parts. 

(e)  At  the  end  of  thirty  days  keep  in  a  storage  of  iodized  solution. 
Preparation  of    Silkworm    Gut. — Place    in    coils    by  winding    four 

strands  around  two  fingers  and  twisting  ends  around  the  coil  three 
times.  Place  coils  in  a  piece  of  gauze,  attaching  a  forceps  and  sterilize 
for  forty-five  minutes.  Preserve  in  the  following  solutions  for:  Bi- 
chloride of  mercury,  1  to  2000;  phenol  solution,  5  per  cent.  Purchase 
hard-twisted  sewing  machine  silk,  as  it  is  the  strongest  made. 

Preparation  of  Horsehair.- — 1.  Scrub  thoroughly  with  green  soap 
and  hot  water.  This  should  be  done  away  from  the  operating  room  as 
horsehair  may  contain  tetanus  bacilli. 

2.  Boil  for  sixty  minutes  in  a  1  per  cent,  sodium  bicarbonate  solution. 

3.  Change  the  water  and  allow  to  boil  for  another  ten  minutes. 

4.  Immerse  in  ether  for  twenty-four  hours  to  remove  fat. 

5.  Wind  in  coils  of  four  strands  each  and  for  final  sterilization  boil 
forty-five  minutes. 


90  ASEPTIC  AND  ANTISEPTIC  TECHNIC 

6.  Preserve  in  any  of  the  following  solutions:  Bichloride  of  mercury, 
1  to  2000;  carbolic  acid,  5  per  cent.;  alcohol,  95  per  cent. 

Preparation  of  Gutta-percha. — 1.  Cut  gutta-percha  into  squares 
6x6. 

2.  Disinfect  a  glass  table  porcelain  tray  or  platter. 

3.  Take  a  square  piece  of  the  rubber  protective  and  place  it  smoothly 
on  the  surface. 

4.  Have  in  readiness  a  basin  of  cold  water  (sterile),  green  soap, 
bichloride  of  mercury,  1  to  500,  and  a  phenol  solution,  5  per  cent. 

5.  Scrub  up  hands  surgically  clean  and  wear  sterile  gloves. 

6.  Scrub  tissue  well  on  both  sides  with  brush  and  green  soap. 

7.  Place  in  a  basin  of  cold  sterile  water. 

8.  Then  transfer  to  basin  of  bichloride  of  mercury,  1  to  500,  to 
remain  twenty  minutes. 

9.  Then  transfer  to  basin  of  phenol  solution,  5  per  cent.,  for  another 
twent}'  minutes. 

10.  Change  gloves  to  another  sterile  pair. 

11.  Place  protective  between  folds  of  gauze  and  keep  in  a  storage 
solution  of  boric  acid,  4  per  cent. 

12.  Cigarette  drains  must  be  handled  carefully,  as  they  tear  easily. 

13.  ]Make  up  not  more  than  two  dozen  at  one  time. 
Preparation  of  Rubber  Tubing. — 1.  Scrub  well  with  green  soap  and 

water  to  remove  all  white  coating  that  is  present. 

2.  Boil  for  ten  minutes  in  a  1  per  cent,  sodium  bicarbonate  solution. 

3.  Scrub  again  if  any  of  the  white  coating  remains. 

4.  Roll  in  a  coil  and  place  in  a  jar  of  cold  water  and  allow  to  sterilize 
by  boiling  for  forty-five  minutes. 

5.  Preserve  in  alcohol,  95  per  cent.;  bichloride  of  mercury,  1  to 
1000;  formalin  solution,  1  to  1000. 

6.  Resterilize  and  change  the  solution  once  weekly. 

Note. — All  glass  drainage  tubes  are  taken  care  of  in  the  same 
manner. 

Bartlett's  Method  of  Preparing  Catgut. — 1.  The  strands  are  cut  into 
convenient  lengths,  say  thirty  inches,  and  made  into  little  coils  about 
as  large  as  a  silver  quarter.  These  coils  in  any  desired  number  are  then 
strung  like  beads  onto  a  thread  so  that  the  whole  quantity  can  be 
conveniently  handled  by  simply  grasping  the  thread. 

2.  The  strings  of  catgut  coils  are  dried  for  four  hours  at  the  following 
temperatures:  160,  180,  200,  220°,  one  hour  each,  the  changes  in 
temperature  being  gradually  accomplished. 

3.  The  catgut  is  placed  in  liquid  albolene,  where  it  is  allowed  to 
remain  until  perfectly  "  clear,"  in  the  sense  that  the  term  is  used  in  the 
preparation  of  histological  specimens.  This  is  usually  accomplished 
in  a  few  hours,  though  it  has  been  my  custom  to  allow  the  gut  to 
remain  in  the  oil  overnight. 

4.  The  vessel  containing  the  oil  is  placed  upon  a  sand-bath  and  the 
temperature  raised  during  one  hour  to  320°  F.,  which  temperature  is 
maintained  for  a  second  hour. 


DISINFECTION  OF  SURGICAL  DRESSINGS  91 

5.  By  seizing  the  thread  with  a  sterile  forceps  the  catgut  is  lifted 
out  of  the  oil  and  placed  in  a  mixture  of  iodin  crystals,  one  part  in 
Columbian  spirits  (deodorized  methyl  alcohol),  one  thousand  parts. 
In  this  fluid  it  is  stored  permanently  and  is  ready  for  use  in  twenty-four 
hours;  the  thread  is  then  cut  and  withdrawn. 

DISINFECTION  OF  SURGICAL  DRESSINGS. 

Manufacturers  have  produced  many  high-pressure  steam  sterilizers 
for  the  disinfection  of  surgical  dressings,  which  are  thoroughly  reliable. 

It  is  necessary  only  to  place  the  dressings  to  be  sterilized  in  suitable 
containers  and  to  carry  out  the  directions  which  come  with  the  sterilizer 
in  use  in  order  to  secure  perfectly  sterilized  dressings. 

The  dressings  should  be  handled  with  the  greatest  care,  to  guard 
against  contamination  at  all  times,  because  persons  who  are  careless 
in  the  manipulation  of  dressing  material  before  sterilization  are  not 
likely  to  use  the  necessary  care  of  the  same  materials  after  sterilization 
has  been  accomplished. 

It  is  important  to  place  the  various  articles  in  convenient  bundles 
in  order  to  reduce  the  likelihood  of  contamination  as  well  as  to  reduce 
unnecessary  waste. 

Gauze  pads  should  be  carefully  folded  in  case  they  are  to  be  used 
for  sponges,  or  for  tampons  or  for  pads  to  be  used  in  performing 
abdominal  sections,  in  order  to  prevent  the  ravellings  from  remaining 
in  the  wound. 

The  pads  should  be  placed  in  uniform  bundles  and  these  folded  in 
pieces  of  muslin  or  in  towels  folded  so  as  to  completely  protect  the 
contents  against  contact  infection.  The  cover  should  be  held  in  place 
by  means  of  pins,  and  the  size,  number  and  kind  of  dressing  should  be 
noted  on  the  cover  by  means  of  a  lead-pencil,  which  will  not  be  erased 
during  the  process  of  sterilization. 

These  bundles  are  then  packed  loosely  into  a  metal  container  so 
constructed  that  it  does  not  interfere  with  the  steam  being  forced 
through  the  dressings. 

It  is  wise  to  place  a  glass  tube  containing  substances  which  change 
color  upon  being  heated  to  100°  C.  in  the  center  of  the  bundles,  in  order 
to  be  certain  that  all  portions  of  the  package  have  been  touched  with 
live  steam. 

Half  an  hour  will  suffice  to  sterilize  surgical  dressings  in  an  apparatus 
containing  high-pressure  superheated  steam,  but  it  is  better  to  leave  the 
dressings  in  the  sterilizer  at  least  one  hour  and  then  to  turn  off  the 
steam  and  permit  the  heat  of  the  apparatus  to  accomplish  thorough 
drying  of  the  dressings. 

The  same  method  will  suffice  for  the  sterilization  of  towels,  gowns 
and  operating  suits. 

These  should  also  be  placed  in  bundles  and  covered  with  muslin 
covers  or  they  may  be  placed  in  muslin  bags  properly  labelled  and 
passed  through  the  sterilizer. 


92  ASEPTIC  AND  ANTISEPTIC  TECHNIC 

Resterilizing  Used  Dressings. ^Before  the  great  war  many  hospitals 
destroyed  all  dressings  after  they  had  been  once  used.  This  resulted 
in  an  enormous  waste  of  material,  but  for  the  sake  of  being  absolutely 
safe,  and  because  in  most  instances  the  cost  did  not  fall  upon  the 
person  who  wasted  the  material,  little  attention  was  paid  to  the  possi- 
bility of  eliminating  this  item  of  waste. 

During  and  since  the  war  many  hospitals  have  ])roved  the  safety 
and  the  economy  of  resterilized  dressings. 

Usually  only  dressings  which  have  not  been  directly  soiled  with  pus 
are  resterilized.  These  dressings  are  first  washed  with  cold  water  until 
they  are  free  from  blood,  then  they  are  boiled  for  half  an  hour  in  a 
steam  laundry  machine,  in  which  the  water  is  kept  at  the  boiling-point 
by  the  forcing  of  live  steam  through  the  apparatus  for  half  an  hour. 

Then  the  dressings  are  placed  in  a  centrifugal  drier,  which  removes 
the  greater  portion  of  the  water.  They  are  then  placed  in  a  drier 
heated  to  a  high  temperature  by  means  of  iron  tubes  carrying  super- 
heated steam.  Then  these  dressings  are  sterilized  on  two  or  three 
successive  days,  according  to  the  method  described  above.  This 
method  is  known  as  fractional  sterilization.  The  method  is  safe  even 
if  dressings  are  resterilized  which  have  been  saturated  with  pus  during 
their  previous  use,  but  it  does  not  seem  wise  to  save  such  dressings  for 
fear  of  harm  coming  through  carelessness  on  the  part  of  some  member 
of  the  personnel. 

In  institutions  in  which  resterilization  is  practised  it  is  wise  to  pur- 
chase a  good  quality  of  gauze,  because  this  can  be  resterilized  many 
times  while  the  poorer  qualities  speedily  become  stringy  and  useless. 

Of  course,  the  muslin  covers  used  to  protect  dressings,  towels, 
aprons,  etc.,  must  be  sterilized  with  the  same  care  as  their  contents, 
although  this  is  not  necessary  theoretically,  because  these  are  sub- 
jected to  the  sterilization  each  time  their  contents  undergo  this  process; 
but  the  nurse  or  other  person  preparing  dressings  should  not  handle 
anything  which  has  been  used  in  the  operating  room  unless  it  has 
previously  passed  through  the  laundry  except  the  material  be  new  and 
have  not  come  in  contact  with  anything  which  might  cause  contami- 
nation. 


ANESTHETICS  AND  ANESTHESIA. 

By  E.  R.  SCHMIDT,  B.A.,  M.D. 

Introduction. — From  the  earliest  practice  of  the  medical  art,  the 
relief  of  pain  has  been  one  of  the  principal  efforts  of  the  physician. 
His  primitive  attempts  varied  from  the  inhalation  of  fumes  to  the 
use  of  weird  incantations  and  hypnotic  spells.  These  eventually  led 
him  to  the  discovery  of  ether,  chloroform  and  nitrous  oxide  gas.  To 
this  trio  more  recent  years  have  added  a  variety  of  other  more  or  less 
efficient  anesthetics  by  which  the  field  and  scope  of  anesthesia  have 
been  steadily  enlarged  until  today  they  have  become  an  essential 
factor  in  surgery.  Under  their  benign  influence  not  only  has  incalcul- 
able human  suffering  been  alleviated,  but  the  science  and  skill  of  the 
modem  surgeon  has  mounted  to  its  present  high  level. 

With  the  discovery  of  ether,  chloroform  and  nitrous  oxide,  general 
anesthesia  was  established.  Ether  has  enjoyed  a  much  wider  use  than 
any  other  single  anesthetic.  Chloroform  was  much  more  popular  in 
England  and  on  the  continent,  than  in  the  United  States;  however, 
there  has  been  a  decline  in  its  use  abroad  and  ether  has  been  substituted. 
The  reason  for  the  employment  of  chloroform  in  the  United  States 
is  explained  by  the  fact  that  students  are  generally  taught  that  it  is 
the  anesthetic  of  choice  in  obstetrical  practice,  and  having  thus  become 
accustomed  to  its  use  they  are  disposed  to  continue  it  in  their  general 
surgery.  However,  the  fact  that  our  medical  schools  are  insisting  upon 
a  year's  internship  in  some  good  hospital  will  undoubtedly  reduce  the 
amount  of  chloroform  employed. 

With  the  work  of  Reclus  local  anesthesia  had  its  beginning.  It 
rather  slowly  won  its  way  at  first,  but  during  the  last  two  decades 
improved  methods  of  administration  have  added  greatly  to  its  popu- 
larity and  enlarged  its  sphere  of  usefulness.  In  skilled  hands  local 
anesthesia  will  suffice  for  almost  any  operation. 

The  results  of  the  War  on  anesthesia  have  not  been  marked.  Local 
anesthesia  has  been  used  with  greater  freedom.  There  have  been 
some  new  appliances  developed  for  the  administration,  suitable  for 
emergency  work  and  under  the  circumstances  that  existed,  but  whether 
they  will  find  a  place  in  civil  practice  is  yet  to  be  seen. 

GENERAL  ANESTHETICS. 

Anesthetics  are  for  general  or  local  effect  and  their  combined  use 
is  not  unusual  in  modern  practice.  General  anesthesia  is  a  state  of 
unconsciousness,  with  more  or  less  complete  loss  of  the  perception  of 

(93) 


94  ANESTHETICS  AND  ANESTHESIA 

])ain  and  relaxation  of  the  voluntary  musculature,  produced  by  tlie 
inhalation  of  ether,  chloroform  or  nitrous  oxide  gas.  Each  of  these 
anesthetics  differs  slightly  from  the  others  in  its  effect.  It  is  a  well- 
known  fact  that  nitrous  oxide  and  oxygen  do  not  cause  the  complete 
relaxation  of  the  \oluntary  musculature  that  attends  the  adminis- 
tration of  ether  or  chloroform.  This  is  especially  noticeable  in  abdom- 
inal operations,  and  in  setting  fractures. 

Ether. — Ether  is  volatile  and  inflammable,  and  the  vapors,  which 
are  about  two  and  a  half  times  as  heavy  as  air,  are  dangerously  explosive 
when  mixed  with  air.  It  is  soluble  in  water  (1  to  10)  and  readily 
soluble  in  alcohol.  It  is  the  anesthetic  par  excellence,  and  its  use  is  more 
general  than  that  of  any  other  anesthetic  agent.  In  using  ether,  one 
must  be  certain  that  it  contains  as  few  impurities  as  possible.  Some 
of  these  impurities  are  alcohols,  peroxide,  aldehydes,  acids  and  fusel 
oil.  These  with  the  exception  of  alcohol  increase  the  irritation  to  the 
mucous  membrane  of  the  respiratory  tract.  It  is  impossible  to  test 
each  package  before  using  it,  but  it  is  possible  to  obtain  ether  free 
from  these  impurities  from  a  reliable  chemical  manufacturer.  How- 
ever, the  fact  that  it  has  been  obtained  from  a  reliable  finn  does  not 
indicate  that  no  attention  need  be  paid  to  the  ether.  One  must  always 
be  guided  by  the  results.  The  amount  used,  the  course  of  the  anesthesia 
and  the  after-effects,  such  as  nausea  and  gas  pains,  are  a  good  index 
to  its  value. 

Ether  depresses  all  parts  of  the  central  nervous  system,  causing  loss 
of  sensation,  loss  of  consciousness  and  abolition  of  the  reflexes.  The 
vital  centers  of  the  medulla  are  involved  very  late  in  the  poisoning, 
making  its  use  much  safer  than  that  of  any  other  anesthetic.  The 
respiration  is  affected  first.  Later  there  is  a  depression  of  the  vaso- 
motor center  and  consequent  fall  of  blood-pressure.  Ether  does  not 
produce  a  marked  effect  on  the  heart.  Its  first  action  is  a  moderate 
reflex  stimulation,  but  in  poisonous  doses  it  depresses  the  heart. 

The  irritating  action  of  the  ether  vapor  on  the  mucous  membrane 
of  the  respiratory  tract  and  on  the  kidneys  is  a  well-known  fact.  With 
the  careful  administration,  that  pre^'ents  an  over-concentration  of  the 
\apor,  this  irritating  action  on  the  respiratory  tract  can  be  reduced  a 
good  deal,  and  also  by  using  as  small  an  amount  as  possible  the  renal 
irritation  "^ill  be  lessened  if  not  avoided. 

Chloroform. — Chloroform  is  a  heavy,  clear,  colorless  and  mobile 
liquid,  of  a  characteristic  odor  and  a  burning,  sweetish  taste.  It  is  but 
slightly  soluble  in  water  (1  to  200),  but  is  miscible  in  all  proportions 
with  alcohol.  It  rapidly  deteriorates  under  the  influence  of  heat, 
light,  and  air.  Hence  it  should  be  stored  in  a  cool,  dark  place,  in  well- 
stoppered  bro"v\Ti  bottles. 

Under  chloroform  the  anesthetic  state  is  more  dangerous  than  with 
ether,  as  there  is  a  gradual,  but  progressive,  fall  of  blood-pressure 
even  if  the  administration  is  carefully  managed.  The  fall  is  due  to 
depression  of  both  the  cardiac  muscle  and  the  vasomotor  center.  The 
respirator}'  center  is  also  depressed,  but  later  than  the  ^•asomoto^ 


GENERAL  ANESTHETICS  95 

Center  and  the  cardiac  muscle,  so  that  if  respiration  ceases,  resusci- 
tation is  more  difficult  than  when  a  like  accident  occurs  under  ether. 

The  irritant  action  on  the  kidneys  and  mucous  membrane  of  the 
respiratory  tract  is  about  the  same  as  with  ether.  There  may  be  a 
delayed  poisoning,  due  to  prolonged  administration,  which  may  occur 
several  days  later.  This  produces  a  fatty  degeneration,  especially  in 
the  liver.  The  irritant  action  of  chloroform  is  especially  marked  in  the 
first  stage,  when  most  of  the  fatalities  occur.  The  use  of  morphin 
and  atropin  preliminary  to  the  anesthesia  reduces  this  danger. 

Ethyl  Chloride. — Ethyl  chloride  was  first  used  by  Hegfelder  in  1848. 
It  is  a  colorless,  volatile  liquid,  having  an  agreeable  odor  and  a  sweetish, 
burning  taste.  It  induces  anesthesia  promptly,  but,  like  chloroform, 
the  danger  of  stoppage  of  the  heart  and  the  depression  of  the  vital 
centers  limit  its  use. 

The  pulse  and  respiration  are  at  first  accelerated,  but  when  the 
stage  of  anesthesia  is  reached  they  should  be  normal.  The  induction 
is  rapid,  usually  two  or  three  minutes  sufficing.  There  is  very  little 
excitement.  Muscular  relaxation  is  not  as .  complete  as  with  ether  or 
chloroform.  Too  concentrated  vapor  is  dangerous,  as  respiration  may 
cease  and  the  diaphragm  go  into  a  state  of  spasm.  Prolonged  adminis- 
tration lowers  blood-pressure,  causes  cyanosis  and  asphyxia,  and  may 
produce  death  from  respiratory  failure. 

Its  use  as  an  anesthetic  is  safer  than  that  of  chloroform  but  not  as 
safe  as  ether.    For  short  operations  it  is  a  quick  and  pleasant  anesthetic. 

Nitrous  Oxide  and  Oxygen. — Nitrous  oxide  has  been  used  alone  as  an 
anesthetic,  but  in  combination  with  oxygen  it  has  become  much  more 
popular.  Nitrous  oxide  is  a  colorless  gas.  It  has  a  pleasant  odor  and 
a  sweetish  taste.  It  should  contain  95  per  cent.  N2O  and  no  solids, 
other  oxides  of  nitrogen  or  organic  matter.  It  is  stored  in  steel  cylinders 
of  various  sizes  in  which  it  has  been  liquefied  under  pressure. 

The  anesthesia  induced  is  rapid  and  pleasant.  There  are  no  definite 
stages,  as  in  ether  and  chloroform,  and  the  patient  passes  quite  rapidly 
into  a  state  of  surgical  anesthesia.  By  varying  the  amount  of  nitrous 
oxide  and  oxygen  given,  the  depth  of  the  anesthesia  can  be  regulated. 
The  elimination  through  the  lungs  is  quite  rapid,  so  that  a  patient 
deep  in  anesthesia  will  soon  awaken  if  given  oxygen  or  air.  The  per- 
centage of  nitrous  oxide  is  gradually  increased  from  2  or  3  per  cent,  at 
the  beginning  to  10  per  cent,  as  the  case  may  demand.  The  longer  the 
anesthesia  lasts  the  greater  should  be  the  percentage  of  oxygen. 

The  muscular  relaxation  in  nitrous  oxide  and  oxygen  anesthesia  is 
not  as  complete  as  with  ether  or  chloroform,  hence  it  is  less  desirable 
for  abdominal  or  fracture  work.  Crile  believes  that  it  produces  less 
shock,  less  nausea,  and  less  lowering  of  vital  resistance  to  infection 
than  does  ether. 

The  administration  of  morphin  previous  to  the  anesthetic,  or  using 
ether  with  the  nitrous  oxide  and  oxygen,  will  aid  in  procuring  muscular 
relaxation. 


96  ANESTHETICS  AND  ANESTHESIA 

The  striking  phenomena  during  its  administration  are  asphyxia, 
stertorous  respiration,  cyanosis  and  even  convulsions,  dilatation  of  the 
pupils,  rapidity  of  the  heart,  and  swelling  of  the  tongue.^  Slowness 
of  the  heart  is  a  danger  sign.  If  nitrous  oxide  causes  death,  it  does  so 
by  asphyxia,  or  by  asphjoda  and  cardiac  inhibition. 

Mixtures. — ]\Iixtures  were  introduced  in  an  efYort  to  reduce  the  mor- 
tality due  to  ether  and  chloroform.  Schleich  said  that  the  further  the 
boiling-point  of  an  anesthetic  was  below  the  human  temperature  the 
less  could  be  introduced  into  the  body  by  inhalation.  With  the  boiling- 
point  about  98.5°  F.  the  lungs  can  regulate  the  elimination,  so  that 
about  as  much  is  exhaled  as  is  inhaled.  When  the  boiling-point  is  about 
149°  F.,  as  in  the  case  of  chloroform,  more  is  inhaled  than  is  exhaled 
and  anesthesia  is  rapid;  an  excess  is  readily  accumulated ,  so  attempts 
were  made  to  secure  mixtures  with  a  boiling-point  that  would  give  an 
ideal  anesthetic. 

Ether  and  Chloroform. — These  may  be  used  in  varying  proportions. 
Hewitt  employs  a  mixture  of  two  parts  of  chloroform  and  tliree  parts 
of  ether.  Tliree  parts  of  ether  and  one  part  of  chloroform,  constitute 
the  Vienna  mixture. 

Alcohol  and  Chloroform. — By  adding  alcohol  to  the  chloroform, 
Sansome  thinks  the  evaporation  of  the  chloroform  is  reduced,  and,  as  a 
result,  there  is  less  concentration.  One  part  of  alcohol  and  four  parts 
of  chloroform  are  used. 

Alcohol,  Chloroform  and  Ether. — This  may  be  used  as  a  mixture  of 
one  part  of  alcohol,  two  parts  of  chloroform  and  three  parts  of  ether. 
Its  action  is  that  of  chloroform  and  ether.  The  materials  do  not  evapo- 
rate at  the  same  rate,  so  that  one  does  not  know  how  much  of  either 
the  patient  is  inhaling. 

BUlroth's  mixture  consists  of  one  part,  of  alcohol,  one  part  of  ether 
and  three  parts  of  chloroform. 

Schleich' s  Mixture. — 

Solution  No.  1  (by  Volume). 

Chloroform giss 

Petroleum  ether gss 

Sulphuric  ether 5vi 

Solution  No.  2. 

Chloroform giss 

Petroleum  ether gss 

Sulphuric  ether §v 

Solution  No.  3. 

Chloroform gj 

Petroleum  ether gss 

Sulphuric  ether gij 

No.  1  is  for  light  anesthesia.  No.  2  for  medium  and  No.  3  for  deep 
anesthesia.  Petroleum  ether  has  no  anesthetizing  power.  Meltzer 
has  shown  that  it  is  dangerous  and  tends  to  paralyze  the  respiratory 
muscle.    The  use  of  mixtures  has  never  gained  a  wide  popularity. 

»  Hewitt:  British  Med.  Jour.,  February  18,  1899. 


GENERAL  ANESTHETICS  97 

Preparation  of  the  Patient  for  Anesthesia. — An  operation  is  just  like 
a  chain  and  the  results  that  the  surgeon  obtains  are  dependent  on  the 
weakest  link  in  his  chain.  Every  patient  should  have  preparation  for 
an  operation,  and  especially  if  a  general  anesthetic  is  to  be  given.  In 
an  emergency  where  there  is  immediate  surgical  intervention,  this  is 
oftentimes  impossible.  The  preparation  should  not  be  too  prolonged 
unless  there  is  some  special  reason,  as  in  a  very  toxic  hyperthyroidism, 
where  the  preparation  for  operation  may  include  preliminary  treat- 
ment extending  over  some  time.  Prolonged  preparation  has  a  bad 
effect  on  the  patient,  as  there  is  always  an  operation  staring  him  in  the 
face. 

The  following  routine  has  been  found  very  successful  at  the  Augus- 
tana  clinic.  A  careful  history  and  physical  examination  are  made  and 
recorded.  The  physical  examination  should  be  made  the  day  before 
operation,  so  as  to  be  certain  that  nothing  new  has  developed.  The 
urine  is  examined  very  carefully  for  albumin,  sugar,  diacetic  acid,  casts 
and  blood.  A  red  and  white  blood-count  is  made,  the  percentage  of 
hemoglobin  determined  and  the  systolic  and  diastolic  blood-pressure 
taken  and  recorded.  The  afternoon  before  the  operation  the  patient^^is 
given  a  warm  bath  if  the  patient's  condition  permits  it.  In  order  to 
clean  the  gastro-intestinal  tract,  early  in  the  afternoon  preceding  the 
operation,  oleum  ricini  (two  ounces),  either  in  the  foam  of  beer  or 
orange-juice,  is  given.  It  is  given  early  so  that  the  effects  of  the 
cathartic  will  be  over  early  in  the  evening  and  the  patient  secures  a  good 
night's  rest.  Of  course,  in  acute  abdominal  conditions  one  should 
never  give  any  cathartic.  The  following  morning  the  patient  receives 
a  soapsuds  enema. 

If  the  patient  has  been  on  a  full  or  modified  diet,  the  evening  meal 
preceding  the  operation  is  limited  to  broth.  The  next  morning  no 
food  is  taken  before  the  operation.  If  there  is  food  in  the  stomach, 
or,  in  cases  of  obstruction,  when  there  is  liable  to  be  some  retention 
of  food,  the  stomach  is  thoroughly  washed  out  with  water  at  a  tempera- 
ture of  105°  to  108°  F. 

In  operations  that  may  be  prolonged  and  in  thyroidectomies,  the 
patient  receives  morphin,  grain  J,  and  atropin,  grain  y^-q  one-half .  hour 
before  commencing  the  anesthesia.  This  permits  a  prolonged  adminis- 
tration of  the  anesthetic.  Less  of  the  anesthetic  will  be  used  and  the 
patient  will  take  it  better.  Also  in  alcoholic  and  very  robust  patients 
morphin  and  atropin  aid  the  anesthetic.  The  fact  that  morphin  and 
atropin  have  been  administered  to  the  patient  should  be  recorded,  so 
that  the  anesthetist  is  aware  of  it,  as  the  pupillary  reaction  will  be 
changed  and  less  anesthetic  will  be  necessary  to  keep  the  patient  under. 

Anesthetist. — -The  anesthetist  should  be  a  medical  man  if  it  is  possible, 
or  a  carefully  trained  woman,  preferably  a  nurse.  The  best  anesthe- 
sias are  conducted  by  women  at  the  present  time,  because  it  is  possible 
to  select  women  with  the  highest  degree  of  intelligence  and  judgment 
for  this  work,  while  medical  men  possessing  these  qualities  can  almost 
never  be  induced  to  elect  anesthesia  as  a  specialty.    Unless  the  person 


98  ANESTHETICS  AND  ANESTHESIA 

gi^•ing  the  anesthetic  makes  a  profession  of  this  work  the  anesthetic 
may  be  jioorly  given  and  the  patient  suffer  as  a  consequence. 

Dr.  Price  defines  an  anesthetic  as  an  agent  by  which  the  patient  is 
carried  to  the  edge  of  death  and  held  there  while  the  surgeon  does  his 
work.  To  accomplish  this  requires  skill,  knowledge  and  practice. 
There  is  no  doubt  but  that  a  layman  can  learn  to  administer  an  anes- 
thetic, and  in  the  majority  of  instances  do  it  very  well.  While  in  France 
the  author  knew  a  medical  corps  sergeant  who  was  able  to  procure 
excellent  anesthesia  with  any  kind  of  an  anesthetic.  He  had  adminis- 
tered anesthetics  many  thousand  times  and  studied  the  subject  thor- 
oughly from  everA'  angle.  But  to  give  an  anesthetic  is  only  a  part  of 
the  task. 

The  personal  bearing  of  the  anesthetist,  his  confidence  in  himself, 
his  method  of  preparing  for  work,  help  a  great  deal  toward  a  successful 
anesthesia.  The  anesthetist  must  be  able  quickly  to  understand  his 
patient.  A  young  boy  or  girl  must  be  differently  handled  from  a  man 
or  woman.  The  patient  must  not  be  frightened.  All  these  particulars 
noted  and  deftly  handled  by  the  anesthetist  enhance  the  prospect  of  a 
good  result. 

For  emergency  there  should  always  be  at  hand  a  mouth  gag,  tongue 
forceps,  artery  forceps  and  gauze  for  wiping  mucus  out  of  the  mouth, 
A  towel  or  two  should  be  convenient  in  case  the  patient  vomits.  A 
h}-podermic,  in  working  order,  strychnin,  brandy,  camphorated  oil 
and  caff ein  citrate  should  be  ready.  A  tank  of  oxygen,  ready  for  admin- 
istration, should  be  accessible.  It  is  a  good  plan,  when  using  the  open- 
drop  method  of  inhalation,  to  have  another  dry  mask  in  reserve. 

When  women  patients  are  being  anesthetized  a  third  person  should 
be  in  the  room.  This  is  an  invariable  rule.  It  is  a  well-known  fact 
that  while  receiving  an  anesthetic  women  ma}'  have  erotic  sensations, 
and  on  awakening  have  declared  that  they  were  raped. 

After  the  patient  is  asleep  it  is  the  dut}'  of  the  anesthetist  to  carry 
the  anesthesia  along  in  a  way  to  help  the  surgeon  as  much  as  possible. 
This  means  he  must  know  the  operation.  For  instance,  when  the 
abdomen  is  being  opened,  to  prevent  the  intestines  from  protrud- 
ing, thus  increasing  shock,  the  patient  must  be  relaxed  and  asleep. 
Then  he  uses  as  little  anesthetic  as  possible,  just  enough  to  keep  the 
patient  unconscious  while  the  abdomen  is  closed  and  the  dressing  put  on. 
The  patient  is  now  almost  conscious.  During  this  time  he  should  be 
kept  warm,  and  to  avoid  paralysis,  the  arms  should  be  prevented 
from  hanging  over  the  edge  of  the  table.  The  patient  should  be  accom- 
panied by  the  anesthetist  to  his  room  and  left  in  the  care  of  a  nurse. 

Methods  of  Administration  of  Anesthetics. — Open-drop  Method. — 
This  is  the  most  commonly  used  method.  By  means  of  a  wire  mask 
covered  with  two  layers  of  gauze,  so  that  the  vapors  are  not  too  dense, 
ether,  chloroform  and  ethyl  chloride  and  the  various  mixtures  of  alcohol, 
chloroform  and  ether  can  be  administered. 

There  are  many  masks  on  the  market,  A  very  satisfactory  one 
is  the  Esmark  mask.    It  is  necessary  that  the  mask  when  applied  to 


GENERAL  ANESTHETICS  99 

the  face,  covers  the  nose  and  mouth,  that  it  fits  the  contour  of  the  face 
snugly,  and  that  on  crossing  the  bridge  of  the  nose  there  is  no  pressure. 
The  gauze  should  not  be  too  thick  or  else  the  vapor  may  become  too 
dense  and  the  patient  will  choke  and  struggle.  One  cannot  say  how 
thick  the  gauze  should  be,  because  of  the  difference  of  the  mesh  and 
texture  of  the  gauze.  A  very  good  method  is  to  take  a  small  piece  of 
stockinette,  such  as  is  used  for  plaster-of-Paris  work,  slip  it  over  the 
frame  and  then  adjust  the  frame.  Take  a  small  piece  of  surgical 
gauze  and  wind  it  around  the  edges,  so  that  it  will  rest  easier  on  the 
face.  By  varying  the  amount  of  ether  dropped  on  the  mask  one  can 
regulate  the  density  of  the  vapor  and  the  depth  of  the  anesthesia.  For 
each  administration  a  dry  piece  of  stockinette  and  a  sterile  frame  are 
used.  The  stockinette  can  be  sterilized  and  used  many  times.  In 
order  to  protect  the  patient's  face  and  eyes  a  drop  of  sterile  oleum 
ricini  is  dropped  in  each  eye  and  a  piece  of  protective  tissue,  which  has 
a  V  cut  out  of  the  middle,  so  that  it  fits  over  the  bridge  of  the  nose,  is 
put  over  the  eyes. 

Open-drop  with  Posture. — In  the  clinic  at  the  Augustana  Hospital 
the  open-drop  method  with  posture  has  been  used  very  successfully 
for  many  years.  This  is  especially  applicable  to  operations  on  the  head 
and  neck.  The  patient  is  thoroughly  anesthetized  in  the  prone  position 
with  ether  by  the  open-drop  inhalation  method.  Then  the  patient  is 
taken  into  the  operating  room  and  the  head  of  the  operating  table  is 
elevated  about  35  degrees.  The  patient  will  remain  in  a  state  of  surgi- 
cal anesthesia  for  from  one-half  to  three-fourths  of  an  hour  without 
further  administration  of  ether.  As  an  adjunct  these  patients  receive 
J  grain  morphin  and  y^o  grain  atropin  one-half  hour  before  operation. 
This  continuance  of  anesthesia  is  possible  because,  as  a  result  of  the 
elevation  of  the  head,  there  is  an  anemia  of  the  brain.  This  method  is 
of  great  value  in  thyroid  operations,  because  a  small  amount  of  ether 
is  used  and  the  shock  is  less.  In  other  operations  on  the  neck  and  head 
the  anesthetist  is  removed  from  the  field  of  operation.  This  method  is 
used  only  with  ether. 

Intratracheal  Insufflation  Anesthesia  (Method  of  Meltzer  and  Auer). — 
This  method  is  of  value  when  operations  are  performed  on  the  head 
and  neck.  The  anesthetist  is  out  of  the  way  and  is  not  so  likely  to 
contaminate  the  field  of  operation.  The  patient  is  first  anesthetized 
in  the  usual  position  with  ether.  When  unconscious  the  head  is  dropped 
over  the  edge  of  the  table  and  a  flexible  rubber  tube,  smaller  in  diameter 
than  the  trachea,  is  passed  into  the  trachea.  This  should  be  done  by  one 
with  experience,  and  should  be  under  the  guidance  of  the  eye.  The  tube 
should  reach  almost  to  the  tracheal  bifurcation. 

To  supply  the  ether  vapor  under  pressure  one  can  use  a  foot  bellows, 
allowing  the  air  to  pass  through  a  container  with  ether.  This  is  the 
simplest.  A  more  complicated  apparatus  has  been  devised  by  Dr. 
Elsberg,  of  New  York.  An  electric  motor  is  used  instead  of  the  foot 
bellows  to  furnish  the  stream  of  air.  The  air  before  entering  the  trachea 
is  warmed  by  passing  through  hot  water.    This  supplies  a  constant 


100  ANESTHETICS  AND  ANESTHESIA 

stream  of  air  under  pressure.  During  expiration  the  lungs  force  the  air 
out  of  the  trachea  around  the  rubber  tube.  Care  must  be  taken  that 
the  pressure  is  not  too  high  and  that  no  ether  is  sprayed  into  the 
trachea.  Ether  can  be  administered  intratracheally  without  a  positive 
pressure.  A  very  simple  way  is  to  attach  to  the  rubber  tube  inserted 
into  the  trachea  a  long  rubber  tube  with  a  glass  funnel.  Over  this 
funnel  a  few  layers  of  gauze  are  placed,  and  on  these  ether  is  dropped. 
This  is  very  simple,  and  one  who  knows  how  to  give  ether  by  the  drop 
method  can  readily  use  this. 

Intrapharyngeal  Administration. — Wliere  the  tubing  would  interfere 
with  operations  on  the  mouth  the  ether  can  be  given  intrapharj^n- 
geally.  Two  soft-rubber  catheters  are  put  into  the  nose,  one  on  each 
side,  and  pushed  back  until  the  ends  reach  the  pharynx.  The  two 
outer  ends  are  coimected  by  means  of  a  glass  Y-tube,  and  the  long 
rubber  tube  with  large  glass  funnel  is  attached.  This  allows  the 
anesthetist  to  keep  away  from  the  field  of  operation  and  leaves  the 
mouth  empty. 

Of  course,  where  hot  irons  and  fire  are  used  in  an  operation  around 
the  neck  or  head,  ether  and  chloroform  are  dangerous.  The  air  pas- 
sages must  be  kept  free.  If  the  jaw  sags  or  the  tongue  drops  back 
an  aseptic  assistant  must  hold  the  jaw  forward.  Mucus  should  be 
wiped  out  of  the  mouth.  A  very  good  precaution  to  prevent  much 
secretion  of  mucus  and  to  reduce  the  amount  of  ether  needed  is  to  give 
the  patient  J  grain  morphin  and  y^o  grain  atropin  one-half  hour 
before  operation. 

Intravenous  Administration. — For  intravenous  administration,  ether  is 
used.  Under  the  influence  of  I  grain  morphin  and  y^  o  grain  atropin,  the 
patient  is  brought  to  the  anesthetic  room.  A  needle  such  as  is  used  in 
giving  intravenous  saline  solutions  is  inserted  into  a  vein  of  the  forearm. 
To  the  needle  is  attached  a  rubber  tube  which  has  a  glass  Y-tube  at 
its  end.  Two  tubes  are  attached.  One  leads  to  a  glass  container, 
having  a  5  per  cent,  solution  of  ether  in  normal  saline;  the  other  goes 
out  to  another  container,  with  only  normal  saline.  Each  of  these  tubes 
has  a  screw  stop-cock  on  it,  so  that  the  flow  from  the  two  containers 
can  be  shut  off  or  regulated  as  desired.  All  the  air  should  be  out  of  the 
tubes  before  starting.  By  turning  the  stop-cock  on  the  tube  leading 
to  the  container  with  the  ether  in  solution  the  anesthesia  can  be  begun. 
As  soon  as  the  anesthesia  is  complete  the  flow  can  be  decreased  to  just 
enough  to  keep  the  patient  properly  anesthetized.  If  the  patient  is 
too  profoundly  anesthetized,  salt  solution  can  be  run  in  until  the 
second  stage  of  anesthesia  returns.  By  regulating  the  flow  from  the 
two  solutions  the  desired  degree  of  anesthesia  can  be  obtained. 

Kuemmel  says  there  is  no  postoperative  headache,  vomiting  or 
nausea.  He  claims  that  it  is  specially  efficacious  in  wasted,  weak 
individuals,  patients  who  have  lost  a  good  deal  of  blood  and  those 
that  are  extremely  exhausted. 

It  is  contra-indicated  in  arteriosclerosis,  myocarditis,  choleniia  and 
plethoric  patients.  Edema  of  the  eyelids  or  conjunctiva  are  signs  for 
discontinuing  the  flow  of  both  solutions. 


GENERAL  ANESTHETICS  101 

This  method,  as  in  intratracheal  administration,  keeps  the  anesthe- 
tist out  of  the  way,  the  respiratory  passages  are  not  irritated  as  much 
and  the  air  passages  are  free  for  the  surgeon.  Usually  ten  minutes 
suffice  to  produce  anesthesia  and  from  200  to  300  c.c.  of  the  solution 
or  about  10  to  15  c.c.  of  ether. 

Rectal  Administration. — ^The  utilization  of  the  colon  for  the  absorp- 
tion of  ether  fumes  necessitates  for  rapid  absorption  an  empty  colon. 
This  is  accomplished  by  giving  oleum  ricini,  ounces  two,  twenty-four 
hours  before  the  operation.  Twelve  hours  later  a  high  soapsuds  enema 
is  given  and  repeated  the  next  morning  before  operation.  In  giving 
the  anesthetic,  oleum  ricini  (sterile)  is  dropped  into  each  eye  and  then 
both  are  covered  with  protective  tissue.  This  is  necessary  to  prevent 
any  trauma  during  anesthesia. 

Around  the  rectum  vaselin  is  spread  so  as  to  prevent  irritation  of  the 
skin.  The  jaws  should  be  held  during  the  anesthesia,  so  as  to  prevent 
the  tongue  from  obstructing  the  air  passage.  The  apparatus  necessary 
is  a  rectal  tube,  a  rubber  tube  leading  to  a  wide-mouthed  bottle,  with  a 
snugly  fitting  rubber  stopper  which  has  two  perforations.  Through  the 
stopper  are  two  glass  tubes,  one  reaching  to  the  bottom  the  other  reach- 
ing just  through  the  stopper.  A  rubber  tube  leading  from  a  foot 
bellows  is  attached  to  the  glass  tube  reaching  to  the  bottom  of  the 
bottle.  The  air  bubbles  through  the  ether  and  becomes  saturated  with 
ether  vapor.  The  short  glass  tube  is  attached  to  a  tube  leading  to  the 
rectal  tube.  The  rubber  stopper  must  fit  snugly;  but  it  should  not  be 
firmly  fixed,  for  it  acts  as  a  safety-valve.  If  pressure  is  too  high  it  will 
come  out  and  prevent  too  much  tension  being  put  on  the  colon. 

The  wide-mouthed  bottle,  which  should  be  at  least  30  cm.  deep,  so 
as  to  allow  the  air  to  go  through  a  long  column  of  ether,  should  be  kept 
at  a  temperature  from  80°  to  100°  F.  This  can  be  accomplished  by 
keeping  the  bottle  in  a  water-bath  and  regulating  the  temperature  of 
the  water  by  a  thermometer.  This  causes  the  ether  to  evaporate  fast 
enough  to  produce  anesthesia  and  supplies  a  warm,  less  irritating  gas 
to  the  bowel.  By  raising  and  lowering  the  temperature  of  the  water 
the  ether  may  be  made  to  evaporate  faster  or  slower. 

On  passing  the  rectal  tube,  all  the  gas  in  the  colon  is  let  out,  and  by 
attaching  the  apparatus,  ether  fumes  are  sent  into  the  colon.  At  first 
there  may  be  some  colicky  pains,  but  as  the  patient  comes  under  the 
influence  of  ether  the  pressure  may  be  increased  until  a  state  of  sur- 
gical anesthesia  results.  By  supplying  from  time  to  time  more  ether 
vapor  the  patient  is  kept  under.  If  anesthesia  becomes  too  deep,  dis- 
connect the  tube  from  the  rectal  tube  and  allow  the  gas  to  escape. 
This  can  be  aided  by  making  gentle  pressure  on  the  abdomen. 

The  amount  of  ether  used  is  small,  one  to  four  ounces  sufficing  for 
most  anesthesias.  Anesthesia  can  be  induced  in  from  five  to  fifteen 
minutes. 

There  is  less  irritation  of  the  respiratory  tract,  and  a  patient  comes 
out  of  the  anesthesia  soon  after  stopping  the  ether  vapor.  Since  less 
mucus,  ladened  with  ether  has  been  swallowed  there  will  be  less  nausea 


102  ANESTHETICS  AND  ANESTHESIA 

and  vomiting.     For  abdominal  operations  this  method  is  undesirable 
because  of  the  distention  of  the  colon  with  ether  fumes. 

In  head  and  neck  operations  it  keeps  the  anesthetist  away  from  the 
field  of  operation.  In  asthenic  cases  and  bad  risks,  especially  in  pul- 
monary tuberculosis  and  chronic  affections  of  the  respiratory  tract, 
rectal  anesthesia  will  reduce  the  irritation  to  the  respiratory  mucous 
membrane. 

Oral  Administration. — Gwathmey  and  Karsner^  found  that  general 
analgesia  was  much  safer  than  general  anesthesia.  They  use  50  per 
cent,  ether  in  some  bland  oil,  such  as  liquid  petroleum.  It  may  be 
sand^^^ched  between  moutlifuls  of  port  wine,  taking  away  the  unpleas- 
ant taste.  There  is  no  deleterious  effect  on  the  stomach,  and  the  nausea 
and  vomiting  are  absent.    It  is  used  for  painful  dressings. 

Closed  Method. — The  closed  method  of  administering  an  anesthetic 
is  not  generally  used  except  with  nitrous  oxide  and  oxygen.  Ether 
has  been  given  a  good  deal  this  way.  It  is  said  to  reduce  acapnia, 
lessen  postanesthetic  nausea  and  practically  abolish  lung  complications. 
In  addition  the  amount  of  ether  used  is  much  less  than  in  the  open 
drop  method. 

There  are  many  closed  inhalers  on  the  market.  The  principle  is  the 
same  as  the  one  used  in  the  Teter  apparatus  for  nitrous  oxide  and 
oxygen.  The  air  is  exhaled  into  a  rubber  bag  and  then  inhaled.  Fresh 
air  may  be  introduced  at  any  time.  During  the  passage  of  the  air  from 
and  to  the  rubber  bag  the  ether  is  added.  Dr.  Rice^  furnishes  the  ether 
vapor  by  allowing  oxj'gen  to  bubble  through  ether  and  enter  into  the 
bag. 

One  objection  to  this  method  is  the  apparatus.  The  more  simple 
the  thing  is,  the  better  it  is.  By  putting  a  towel  over  the  mask  used 
in  the  open-drop  inlialation  method  a  semiclosed  method  results. 
Gwathmey  in  liis  book  on  Anesthesia  says  that  in  the  closed  method 
there  is  an  anoxemia  and  a  danger  of  too  concentrated  ether  vapor. 
The  excess  of  carbon  dioxide  stimulates  respiration,  and  an  overdose 
of  the  ether  is  very  likely.  This,  of  course,  must  be  regulated  by 
admitting  free  air  from  time  to  time. 

^Yith  nitrous  oxide  and  oxygen  the  mask  is  put  over  the  face,  so  as 
to  cover  the  nose  and  mouth.  Nitrous  oxide  is  run  into  the  rubber 
bag  and  the  patient  breathes  it  in.  If  the  patient  is  difficult  to  put  to 
sleep  the  bag  may  be  a  little  overdistended.  In  about  two  or  three 
minutes  the  anesthesia  will  be  completed.  As  the  patient  is  going 
under,  oxygen  may  be  added.  The  amount  and  proportion  of  oxygen 
and  nitrous  oxide  used  will  be  determined  by  the  condition  of  the 
patient.  Ether  may  be  added  when  the  anesthesia  is  prolonged,  or 
complete  relaxation  of  the  voluntary'  musculature  is  required. 

Sequence  Administration. — The  preliminars*  stage  with  some  anes- 
thetics is  aimo^ing  to  patients,  especially  if  they  have  to  take  ether  a 
second  time.    To  ob\"iate  this,  other  anesthetics  have  been  used  for 

1  British  Med.  Jour.,  March  2,  1918. 

-  American  Year  Book  of  Anesthesia  and  Analgesia,  1915. 


GENERAL  ANESTHETICS  lOS 

the  initial  stage  and  then  followed  by  ether.  The  most  commonly 
used  are  nitrous  oxide  and  oxygen  followed  by  ether.  Chloroform 
may  be  used  because  it  is  more  pleasant  and  ethyl  chloride  may  be 
employed.  These  are  usually  administered  by  the  open-drop  method. 
Oral  analgesia  and  intravenous  or  rectal  anesthesia  may  be  used  to 
induce  the  anesthesia  which  is  then  completed  with  ether  by  the 
open-drop  method. 

Choice  of  Anesthetic. — ^The  choice  of  an  anesthetic  depends  on 
several  factors.  The  prime  factor  is  the  safety  of  the  patient.  McGrath^ 
reports  49,057  anesthetics  with  ether  and  no  fatalities.  At  the  Augus- 
tana  Hospital  there  have  been  over  20,000  ether  anesthesias  with  no 
fatality.  This  makes  no  fatality  in  almost  70,000  ether  administrations. 
There  are  many  statistics  on  the  mortality  due  to  anesthetics,  and  they 
vary  greatly.  This  variation  may  be  due  to  tw^o  things:  (1)  the  anes- 
thetic itself,  or  (2)  the  administration  of  the  anesthetic.  Both  of  these 
conditions  can  be  controlled.  A  good  grade  of  the  drug  must  be  used 
and  one  expert  in  its  administration  must  give  it. 

Ether  is  used  more  generally  than  any  other  anesthetic.  It  gives 
complete  unconsciousness  and  a  relaxation  of  the  voluntary  muscula- 
ture. In  acute  respiratory  diseases,  chronic  bronchitis,  obstruction 
to  the  air  passages,  arteriosclerosis,  hypertension  and  atheroma  the 
use  of  ether  is  more  dangerous.  Since  ether  affects  the  respiratory 
center  before  it  does  the  vasomotor  center  and  cardiac  muscles,  it  is 
much  easier  to  give,  and  easier  for  a  patient  to  recover  if  too  much  has 
been  given. 

Chloroform  has  a  pleasant,  sweetish  odor  and  is  agreeable  to  take. 
In  obstetrical  work  it  may  be  administered  with  relative  safety. 
Because  of  the  danger  of  reflex  stoppage  of  the  heart,  late  poisoning 
and  the  early  depression  of  the  vasomotor  center  it  is  more  dangerous 
than  ether.  It  has  an  irritating  effect  on  the  mucous  membrane  of  the 
respiratory  passages.  It  is  much  more  dangerous  in  shock  than  ether. 
In  acute  pathological  processes  in  the  lungs,  emphysema,  pulmonary 
tuberculosis,  in  marked  kidney  diseases,  in  valvular  disease  of  the  heart 
with  hypertension  and  myocardial  disease,  chloroform  should  not  be 
used. 

Ethyl  Chloride. — Ethyl  chloride  has  the  same  disadvantage  for  general 
use  as  chloroform.  Great  care  must  be  exercised  in  giving  it.  The 
vapor  must  not  be  too  concentrated  and  a  semiclosed  method  used  in 
its  administration.  It  is  easy  to  give  an  overdose  and  cause  death  by 
respiratory  failure  and  spasm  of  the  diaphragm. 

Nitrous  Oxide  and  Oxygen.-^Nitrous  oxide  and  oxygen  combined,  make 
one  of  the  safest  anesthetics.  Because  of  an  incomplete  relaxation  of  the 
voluntary  muscles  it  is  less  desirable  than  ether.  It  should  not  be  used 
in  plethoric  patients,  in  myocardial  disease,  valvular  heart  disease  or  in 
any  case  with  obstruction  to  the  respiratory  passages,  severe  anemia, 
hypertension,  diabetes,  and  status  lymphaticus.    It  necessitates  a  much 

1  Collected  Papers  of  Staff  of  St.  Mary's  Hospital,  Mayo  Clinic,  1913. 


104  ANESTHETICS  AND  ANESTHESIA 

more  complicated  apparatus,  and  as  the  gas  is  in  steel  cylinders,  its 
transportation  is  more  difficult.  For  these  reasons  nitrous  oxide  and 
oxygen  have  not  been  used  generally  except  in  extracting  teeth,  open- 
ing abscesses  and  in  operations  that  are  short  and  where  muscular 
relaxation  is  not  essential.  It  is  often  used  in  combination  with  ether, 
and,  in  the  hands  of  an  expert,  a  very  safe  and  satisfactory  anesthesia 
can  be  secured. 

COMPUCATIONS. 

The  postoperative  complications  that  occur  are  due  to  (1)  condition 
of  the  patient;  (2)  anesthetic  given  and  (3)  operation  performed. 

If  the  patient  is  in  a  very  poor  physical  condition,  the  anesthetic 
poorly  gi^'en  and  an  extensive  operation  performed,  it  stands  to  reason 
that  complications  will  be  met.  Cutler  and  Morton,^  using  the  statistics 
of  operation  at  the  Massachusetts  General  Hospital  (3490  cases), 
came  to  the  following  conclusions  regarding  the  predisposing  factors 
causing  postoperative  complications: 

1.  Poor  general  condition;  age,  anemia,  alcoholism,  arteriosclerosis, 
a  weak  myocardium  or  chronic  infections  of  the  lungs. 

2.  Oral  sepsis:  carious  teeth,  septic  tonsils. 

3.  Badly  given  anesthetic,  forced,  aspiration  of  mucus,  unnecessary 
intubation  of  esophagus,  vomiting  on  table  with  aspiration  of  vomitus. 

4.  Presence  of  septic  foci. 

5.  Too  radical  operations  that  open,  unnecessarily,  pathways  to  the 
neighborhood  of  the  lungs  and  the  lungs  themselves. 

6.  Operations  in  the  epigastrium  carry  the  added  danger  of  lung 
complication  tlirough  ease  of  vascular  and  lymph  extension. 

7.  Exposure  to  cooling  fluids  or  to  draughts  (vasomotor  disturb- 
ances) . 

8.  Postoperative  pain  resulting  in  hypostasis  from  poo  expansion. 
They  further  noted  that  1  in  every  54  patients  operated  upon  devel- 
oped postoperative  lung  condition  and  that  1  in  106  died. 

There  are  a  good  many  factors  entering  in. 

The  lung  complications,  such  as  lobar  pneumonia,  bronchopneu- 
monia, bronchitis,  pleurisy,  empyema,  pneumothorax,  mediastinitis, 
pulmonary  embolism,  and  lung  abscess  are  most  common.  By  giving 
the  anesthetic  carefully,  using  as  little  as  is  necessary  and  not  forcing 
the  anesthesia,  there  is  much  less  irritation.  Morphin  and  atropin 
will  diminish  the  secretion  of  mucus  and  less  anesthetic  will  be  required. 
The  treatment  immediately  after  operation  is  most  important.  If 
possible,  changing  the  position  of  the  patient  every  two  or  three  hours 
will  prevent  a  hypostatic  congestion.  The  Fowler  position  will  also 
help,  and  the  patient's  head  should  be  elevated  12  to  18  inches  when- 
ever any  evidence  of  puhnonary  irritation  follows  an  operation.  This 
plan  of  treatment  almost  entirely  eliminates  postanesthetic  pneumonia. 

Nausea  and  \omiting  are  chiefly  due  to  swallowing  mucus  laden 

*  Surg.,  Gynec.  and  Obst.,  December,  1917. 


COMPLICATIONS  105 

with  ether,  but  there  may  be  some  regurgitation  from  the  duodenum. 
By  ^yashing  the  stomach  the  nausea  and  vomiting  are  reheved.  Pre- 
venting the  excessi\'e  secretion  of  mucus  and  having  the  gastro-intes- 
tinal  tract  clean  will  reduce  the  nausea  and  vomiting.  The  patient 
should  be  almost  or  wholly  conscious  when  put  to  bed  after  an  oper- 
ation. He  should  be  able  to  cough  up  any  vomited  material  that 
might  other^'ise  go  down  the  trachea,  and  expel  excessive  secretions 
that  may  collect  in  the  respiratory  tract.  Drinking  hot  water  tends  to 
dilute  the  mucus  and  wash  it  out  of  the  stomach. 

Anuria  occurs  occasionally  after  an  operation.  One  must  first  be 
certain  that  it  is  an  anuria  and  not  simply  an  inability  to  void.  This 
can  be  done  by  catheterization.  Care  must  be  exercised  in  catheter- 
izing  a  patient,  so  as  not  to  infect  the  bladder  and  produce  a  cystitis. 
If  an  anuria  exists  the  fluid  intake  should  be  increased  by  means  of 
hj'podermoclysis,  proctoclysis  and  water  by  mouth.  Water  is  the  best 
diuretic.  Stimulate  elunuiation  through  the  skin  by  hot  packs  and 
electric  lights,  through  the  gastro-intestinal  tract  by  means  of  saline 
cathartics,  if  it  is  permissible.  In  abdominal  operations,  cathartics 
immediately  and  for  several  days  after  anesthesia,  are  contra-indi- 
cated. Diuretics,  such  as  diuretin  and  caffein  citrate,  may  aid.  As 
a  final  resort  the  capsules  of  the  kidneys  may  be  split.  This  may  prove 
successful  when  all  other  measures  fail. 

Inability  to  void  the  urine  after  an  operation  is  due  to  a  reflex 
spasm  of  tbe  internal  spliincter.  Increasing  the  fluid  intake,  as 
described  under  anuria,  \\\\\  sometimes  aid.  Usually  there  is  plenty  of 
urine  secreted.  Running  water  in  the  room,  applying  a  hot  pack  to 
the  perineum  or  allowing  the  patient  to  sit  up  will  often  correct  this 
trouble.  Giving  the  patient  an  acid,  so  as  to  increase  the  acidity  of  the 
urine,  will  cause  irritation  at  tbe  internal  spliincter  and  the  urine  may 
be  voided.  As  a  last  resort  the  patient  should  be  catheterized.  Usually 
one  catheterization  will  suffice.  If  not  the  patient  must  be  carefully 
watched  and  should  be  catheterized  every  twelve  hours.  Catheteriza- 
tion must  be  performed  with  surgical  asepsis,  and  even  then  occa- 
sionally a  cystitis  results. 

Gas  pains  are  prevented  by  a  thorough  preliminary  preparation. 
The  gastro-intestinal  tract  is  clean  and  there  is  no  opportunity  for  stag- 
nation and  fermentation.  Limiting  the  diet  to  broth  the  evening  before 
operation  is  important. 

Backache  may  be  complained  of  by  the  patient.  This  is  usually 
located  in  the  lumbar  and  sacral  regions.  Dr.  Dunlop^  believes  it  is 
due  to  the  posture  on  the  operating  table.  There  is  a  strain  due  to 
lack  of  support  to  the  lumbar  curve  and  a  strain  of  the  iliosacral  syn- 
chondrosis results.  Placing  a  small  pillow  under  the  back  during 
operation  will  obviate  this. 

Nephritis  is  usually  transient  if  the  kidneys  are  normal.  Gi\dng  the 
patient  water  to  drink,  preferably  distilled,  as  soon  as  possible  and 

1  New  York  Med.  Jour.,  July  10,  1909. 


106  ANESTHETICS  AND  ANESTHESIA 

continuing  to  force  it  for  a  time,  will  soon  clear  up  this  condition. 
If  the  process  in  the  kidney  is  chronic,  water,  together  with  diuretics, 
should  be  employed.  Diaphoretics  and  cathartics  when  indicated 
may  be  given.  Usually  their  use  is  limited.  Because  more  ether  than 
chlorofonn  is  generally  given  the  irritant  action  of  ether  seems  to  be 
greater.  When  a  patient  has  clironic  nephritis  the  function  of  the 
kidneys  should  be  carefully  studied  before  operation. 

The  degree  to  which  a  patient  is  shocked  depends  chiefly  on  the 
])atient's  ])hysical  condition  before  operation.  A  prolonged  operation, 
with  a  great  deal  of  tramnatism  to  the  tissues,  exposure  of  and  hand- 
ling of  the  intestines,  a  poor  anesthesia,  an  excessive  dose  of  the 
anesthetic  or  exposure  to  cold  during  the  operation  conspire  in 
producing  shock. 

This  condition  will  be  proclaimed  by  a  low  blood-pressure,  poor 
heart  action,  with  a  weak,  small  and  rapid  pulse,  pallor,  cold  sweat, 
feeble  respirati©ns.    The  patient  may  be  conscious  or  unconscious. 

The  treatment  consists  in  prevention.  The  sui'geon  must  be  able 
to  judge  how  much  he  can  do  without  shocking  the  patient.  The  oper- 
ation should  be  as  short  as  possible.  Xo  unnecessary  trauma  or  hand- 
ling of  the  intestines  should  be  done.  If  the  intestines  are  exposed 
they  must  be  covered  with  gauze  moistened  in  hot  saline  solution.  If 
possible  th».\v  should  remain  in  the  abdomen.  There  should  be  as 
little  loss  of  blood  as  possible.  The  anesthetic  should  be  given  by  an 
expert  and  just  as  little  used  as  is  required  to  perform  the  operation. 
Care  must  be  exercised  in  choosing  an  anesthetic. 

During  the  operation  the  patient  should  be  kept  warm  on  the  operat- 
ing table.  Whole  blood  transfusion  by  the  Percy  method,  hj-podermoc- 
lysis  of  saline  solution,  elevation  of  the  foot  of  the  bed  and  applica- 
tion of  external  heat,  by  means  of  blankets,  hot-water  bottles,  and 
electric  lights,  tend  to  combat  shock. 

LOCAL  ANESTHETICS. 

Local  anesthesia  was  practised  in  ancient  times  by  the  inunction  of 
various  narcotics.  There  was  little  progress  made  in  this  art  until 
the  latter  part  of  the  nineteenth  century. 

In  1884  Karl  Roller,  of  Vienna,  demonstrated  the  effects  of  cocain 
as  a  local  anesthetic  before  the  Ophthalmological  Congress  at  Heidel- 
berg. Later,  Merling  discovered  Alpha  and  Beta  eucain,  and  stovain 
was  sVntheticalh'  produced  by  Fourneau.  Since  that  time  the  scope 
and  use  of  local  anesthesia  has  slowly  increased.  The  introduction  of 
the  syringe  in  1845  by  F.  R^md,  of  Edinburgh,  contributed  an  impetus 
to  this  metliod  of  anesthesia. 

In  1884  Halstead  and  in  1885  Corning  demonstrated  clinically  the 
value  of  cocain.  Hall  and  Halstead  also  demonstrated  that  injecting 
a  nerve  trunk  caused  a  sensory  paralysis  in  its  course.  This  work  was 
expanded  by  Crile,  Cushing,  and  Matas.  The  development  of  anoci- 
association  by  Crile  has  given  an  added  value  to  local  anesthesia. 


LOCAL  ANESTHETICS  107 

During  tht:  last  two  decades  its  use  has  become  more  general,  until 
now,  in  the  hands  of  a  skilled  operator,  any  operation  may  be  per- 
formed under  local  that  has  been  done  under  general  anesthesia. 
There  are  none  of  the  accidents  that  happen  during  the  use  of  a  general 
anesthetic  and  no  postanesthetic  complications  except  vomiting  and 
pneumonia.  The  only  disadvantage  is  the  fact  that  the  patient  is 
conscious  and  may  become  alarmed.  However,  this  factor  together 
with  a  perfect  injection  depend  on  the  skill  and  ingenuity  of  the  oper- 
ator. Some  men  are  so  skilled,  can  so  dominate  the  consciousness  of 
their  patients  that  they  are  able  to  do  almost  any  operation.  Farr^ 
cites  77  cases  '.n  children,  and  almost  every  part  of  the  body  was 
operated  upon.  He  says  the  psychic  element  is  not  so  important,  and 
sometimes  restraint  is  necessary.  The  anesthesia  must  be  complete 
and  the  surgical  technic  refined. 

The  scope  of  local  anesthesia  has  been  broadened  by  the  knowledge 
that  viscera  innervated  by  purely  visceral  nerves  are  insensitive,  and 
sensation  exists  only  in  those  that  receive  branches  from  the  somatic 
nerves.  Lennander-  shows  that  the  parietal  peritoneum  is  sensitive  to 
pain  but  not  to  touch.  The  intestine,  stomach,  edges  of  the  liver, 
mesentery,  gall-bladder,  urinary  bladder,  kidney  parenchyma,  lung, 
anterior  wall  of  the  trachea,  testicle  and  epididymis  are  insensitive, 
but  the  coverings  of  the  testicles  and  epididymis  are  sensitive. 

Action.- — ^Local  anesthetics  produce  anesthesia  over  a  limited  area 
in  three  ways:  (1)  by  an  anemia  of  the  capillaries  supplying  the  nerve 
endings;  (2)  by  direct  action  on  the  nerve-endings;  (3)  by  direct  action 
on  the  nerve  fibers.  It  has  been  shown  that  by  injecting  normal  saline 
under  pressure,  anesthesia  will  result.  No  doubt,  in  different  local 
anesthetics,  their  effectiveness  depends  on  whether  they  act  in  all 
tln^ee  ways  or  in  only  one  or  two. 

The  action  may  be  intensified  in  various  ways.  Corning,  and  Oberst, 
of  Halle,  by  applying  a  tourniquet  proximal  to  the  area  anesthetized, 
increased  the  anesthesia  because  of  the  increase  of  the  anemia.  Braun 
used  adrenalin  with  his  injecting  solution  and  prolonged  the  anesthesia, 
due  to  the  greater  anemia. 

It  is  to  Schleich  that  we  owe  the  introduction  of  weaker  solutions 
and  a  greater  use  of  local  anesthesia.  There  is  thus  less  danger  of 
poisoning  and  a  greater  area  is  anesthetized.  Reclus,  Schleich,  Braun, 
and  Puchet  showed  clinically  that  a  large  quantity  might  be  injected, 
but  that  1|  to  3  grains  of  cocain  is  the  maximum. 

Preparation  of  Solutions. — As  a  result  of  the  work  of  Schleich, 
weaker  dilutions  of  the  agent  are  used.  It  is  preferable  to  use  salt 
solution  as  the  diluent,  for  if  the  solution  is  not  isotonic  there  will  be 
an  irritation  and  traumatism  of  the  tissues.  Following  the  injection 
there  will  be  a  reaction. 

The  solution  prepared  must  be  sterile.  Some  drugs,  such  as  cocain, 
break  down  upon  heating,  so  a  sterile  solution  must  be  prepared  by  dis- 

1  Interstate  Med.  Jour.,  February,  1919. 

2  Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1902,  Bd.  x,  Hefte  1  und  2. 


lOS  ANESTHETICS  AND  ANESTHESIA 

solving  the  sterile  cocain  in  sterile  water.  Fresh  solutions  should  be 
prepared  often,  as  it  soon  deteriorates.  Stovain,  novocain  and  alypin 
may  be  boiled  and  a  sterile  solution  obtained. 

The  addition  of  adrenalin  intensifies  the  action  by  increasing  the 
local  anemia,  and  thus  reduces  hemorrhage  during  the  operation.  The 
disadxantage  of  using  adrenalin  is  that  there  may  be  delayed  bleeding. 
Usually  ten  minims  of  a  1  to  1000  solution  of  adrenalin  to  100  c.c. 
of  solution  is  sufficient. 

T.  Sollman^  finds  the  alkalinization  increases  the  efficiency  from  two 
to  four  times.  The  anesthetic  salts  may  be  mixed  with  an  equal  volume 
of  0.5  per  cent,  sodium  bicarbonate  solution  without  loss  of  efficiency 
and  one-half  of  the  anesthetic  is  saved. 

Eggleston  and  Hatcher-  find  that  the  toxicity  of  tlie  different  drugs 
varies  and  depends  on  the  rate  of  their  absorj^tion  and  elimination 
from  the  system.  Usmg  epinephrin  delays  the  absorption,  gixes  the 
system  more  of  a  chance  to  eliminate  and  so  reduces  the  toxicity.  The 
elimination  is  due  to  destruction  of  the  drug  in  the  liver. 

They  find  that  death  is  due  to  paralysis  of  the  heart  and  respiratory 
center.  By  artificial  respiration  and  intravenous  injection  of  epineph- 
rin the  patient  may  be  carried  along  untU  the  system  has  had  a 
chance  to  eliminate  some  of  the  drug.  They  advise  using  epinephrin 
in  solution  of  alypin,  apothesin,  beta-eucain,  nervanin,  procain  (novo- 
cain) stovain  and  tropacocain,  as  it  delays  the  absorption  and  allows 
time  for  destruction  of  the  poison.  It  prolongs  the  anesthesia  and 
reduces  the  amount  of  the  anesthetic  required. 

Morphin  and  Atropin. — As  an  adjunct  to  all  local  anesthesia  the 
use  of  morphin  and  atropin  is  indicated.  By  depressing  the  higher 
centers  the  perception  of  painful  stimuli  is  not  so  acute  and  an  anes- 
thetic that  might  have  been  a  failure  is  a  success.  It  is  also  easier  for 
the  surgeon  to  dominate  the  situation  and  gain  the  confidence  of  the 
patient.  For  adults  I  grain  of  morphin  and  a  y^  grain  of  atropin  are 
used.  For  children  the  dose  is  reduced  to  j^  or  yV  grain  of  morphin 
and  yi|j  to  2^^o^  grain  of  atropin. 

Cocain. — Cocain  is  derived  from  several  varieties  of  cocoa.  It  forms 
colorless  prisms  and  has  a  slightly  bitter  taste.  It  is  slightly  soluble 
in  water  (1  to  600),  freely  so  m  alcohol  (1  to  5).  In  fixed  oils  it  is 
soluble,  but  insoluble  in  petrolatum  and  lard.  The  hydrochloride 
that  is  most  commonly  used,  is  freely  soluble  in  water.  On  boiling  it  is 
hydroHzed  into  egonin,  benzoic  acid  and  meth}'l  alcohol. 

If  too  large  a  dose  is  used  or  a  person  has  an  idiosyncrasy  for  it, 
symptoms  of  poisoning  develop.  At  first  there  is  a  stimulation  of  the 
different  segments  of  the  central  nervous  system.  The  exaltation  in 
the  brain  has  usually  passed  into  depression  by  the  time  the  spinal 
segments  are  reached,  so  that  there  may  be  a  mixture  of  depression 
and  stimulation.  Muscular  irritability,  loss  of  sense  of  fatigue, 
increased  psychic  activity  and  insomnia  are  evidence  of  stimulation. 

1  Jour.  Am.  Med.  Assn.,  January  26,  1918. 

2  Ibid.,  October  25.  1919. 


LOCAL  ANESTHETICS  109 

Somnolence,  stupor  and  coma  show  that  depression  has  set  in.  Respira- 
tion may  be  of  the  Chejoie-Stokes  A^ariety,  and  is  usually  quickened. 
Later,  respiratory  paralysis  may  set  in.  The  heart-rate  is  increased 
at  first  but  later  becomes  weak,  and  the  blood-pressure  falls  as  vaso- 
motor paralysis  appears. 

Cocain,  in  addition  to  its  anesthetic  effect  is  a  vasoconstrictor  and 
is  often  used  in  nasal  work  to  shrink  the  mucous  membrane. 

Eucain. — There  is  an  alpha  and  a  beta  eucain.  The  beta  compoimd 
is  less  irritating  and  toxic  than  the  alpha.  It  has  the  same  anesthetic 
action  as  cocain,  but  instead  of  vasoconstriction  it  produces  a  slight 
vasodilatation.  The  salts  of  eucain  are  fairly  soluble  in  water,  espe- 
cially the  hydrochlorate  and  the  lactate.  It  is  a  s\-nthetic  preparation 
and  derived  from  benzoyl.  Its  action  is  said  to  be  slower  than  that  of 
cocain  or  novocain  but  after  its  action  has  begun  the  anesthesia  lasts 
as  long.    It  is  far  less  toxic  than  cocain. 

Tropacocain. — Tropacocain  is  derived  from  the  same  source  as  cocain. 
It  is  benzoyl  tropin  and  its  action  is  similar  to  cocain.  However,  its 
induction  of  anesthesia  is  quicker  and  does  not  last  as  long  as  cocain. 
It  is  about  one-half  as  toxic.  It  has  no  vasoconstrictor  or  vasodilator 
action.    It  has  been  used  for  the  most  part  in  spinal  anesthesia. 

Stovain. — Stovain  is  also  a  benzol  derivation.  It  is  readily  soluble 
in  water  and  has  been  used  a  great  deal  in  spinal  anesthesia.  It  can 
be  heated  to  120°  C.  before  it  begins  to  decompose.  There  is  some 
irritating  action  on  nerve  tissue,  and  the  anesthetic  effect  is  less  intense 
and  of  shorter  duration  than  that  of  cocain.  ^Yhen  injected  into  tissues 
at  first  there  is  a  slight,  burning  pain,  then  anesthesia  follows.  Fol- 
lowing the  anesthesia  there  is  often  an  inflammatory  reaction  and  if 
strong  solutions  up  to  10  per  cent,  are  used  there  may  be  marked 
tissue  necrosis. 

Novocain  (American  Procain) . — Novocain  hydrochloride  was  intro- 
duced by  Einhorn  in  1905.  It  is  less  irritating  and  toxic  than  cocain 
or  eucain.  It  is  soluble  in  water  in  equal  parts  and  1  to  30  in  alcohol. 
Heating  to  120°  C.  will  not  decompose  it,  and  it  may  be  kept  in  solution 
for  a  long  time.  In  anesthetic  action  a  1.25  per  cent,  solution  has  the 
same  effect  as  a  1  per  cent,  solution  of  cocain,  and  has  about  |  of  the 
toxicity  of  cocain.  The  anesthetic  action  will  not  last  as  long  as  cocain. 
However,  by  adding  adrenalin  its  action  is  intensified  so  as  to  make  it 
equivalent  to  cocain  and  while  the  action  is  not  so  rapid  it  may  last 
longer.  There  is  no  vasomotor  distmbance,  irritation  of  the  tissues 
or  postanesthetic  inflammation.  In  the  eye  its  action  is  much  slower, 
but  it  does  not  damage  the  cornea  as  does  cocain. 

Aljrpin. — Alypin,  a  derivative  of  the  benzoyl  group,  was  introduced 
by  Imperes.  It  is  readily  soluble  in  water  and  alcohol  and  is  not  decom- 
posed by  boiling.  It  is  a  white,  crystalline  powder.  The  anesthetic 
power  is  about  the  same  as  that  of  cocain.  Injection  of  al\-pin  causes 
a  slight  burning  sensation  and  some  h^-peremia.  Its  anesthetic  action  is 
of  shorter  duration  than  cocain,  but  the  addition  of  adrenalin  will 
prolong  its  action.   There  is  less  irritation  and  toxicity  than  with  cocain. 


110  ANESTHETICS  AND  ANESTHESIA 

In  the  eye  there  is  no  drying  of  the  cornea,  no  dilatation  of  the  pupils 
nor  changes  in  accommodation  and  tension.  Cocain  in  the  hands  of 
the  skilled  has  proved  far  superior.  Drs.  Bransford  Lewis  and  Willy 
Meyer  recommend  alypin  in  the  genito-urinary  tract.  Dr.  Meyer 
uses  a  2  per  cent,  solution  for  instillation. 

Anesthesin. — Anesthesin  has  found  its  greatest  use  in  topical  appli- 
cation. It  is  a  fine,  white  crystalline  powder  and  melts  at  90°  C. 
Prolonged  boiling  will  cause  decomposition.  It  is  non-irritating  and 
almost  non-toxic.  It  is  insoluble  in  cold  water,  but  slightly  soluble  in 
warm  and  hot  water.  It  is  soluble  in  alcohol,  ether  and  benzin,  but 
less  so  in  fatty  oils. 

If  left  on  a  surface  undisturbed  its  anesthetic  action  reaches  its 
maximum  in  ten  minutes  and  lasts  for  hours.  This  has  a  varied  use 
in  otalgia,  painful  open  wounds,  continued  \omiting,  itching,  vesical 
and  rectal  ii'ritations  and  ulcers. 

Apothesin. — Apothesin  is  an  American  product.  It  occurs  in  small, 
snow-white  crystals  and  melts  at  137°  C.  It  dissolves  in  alcohol  and 
water  and  is  slightly  soluble  in  acetone  and  ether.  There  is  very 
slight  irritation  and  no  toxic  effect.  The  action  is  quite  rapid  and  lasts 
for  some  time.  During  the  war,  because  of  a  scarcity  of  foreign-made 
local  anesthetics,  apothesin  came  quite  widely  into  use.  It  has  been  a 
very  efficient  agent,  and  in  its  toxicity  and  slight  irritating  effects  it 
resembles  novocain. 

Quinine  Salts. — The  hydrochloride  of  quinine  and  urea  is  the  most 
soluble  of  the  quinine  salts.  Its  anesthetic  effect  is  not  so  rapid  in 
infiltration  and  in  topical  application,  but  its  effect  lasts  a  great  deal 
longer  than  cocain,  novocain,  or  eucain.  There  is  no  diffusion  of  the 
anesthetic  action,  and  vasodilatation  favors  capillary  oozing.  Follow- 
ing the  injection  and  depending  on  the  concentration  there  is  some 
induration.  As  a  local  anesthetic  agent  it  can  be  used  for  almost  any 
operation.  The  serious  drawback  is  this  hard  swelling  and  a  capillary 
oozing  from  the  wound.  This  prevents  rapid  healing  by  first  intention. 
Dr.  F.  W.  Parham^  calls  attention  to  tetanus  following  the  injection 
of  quinine  solution  for  malaria.  Dr.  C.  W.  Allen,  discussing  it  in  his 
book  on  Local  and  Regional  Anesthesia,  thinks  there  is  a  necrosis  of 
the  tissue  with  a  suitable  place  for  the  tetanus  spore  to  develop; 
because  of  low  toxicity  and  of  long-lasting  anesthesia  the  quinine  salts 
are  often  used  in  local  anesthesia. 

Dr.  C.  W.  Allen,^  quoting  from  Piquaud  and  Dreyfus,^  sa}'s  that 
cocain  is  the  most  powerful  of  all  local  anesthetics,  but  its  high  toxicity 
renders  it  dangerous;  a  safe  dose  should  not  exceed  14  to  15  eg.  in  1  to 
200  solution,  care  being  taken  to  maintain  the  recumbent  position 
during  and  after  its  use.    Dr.  Allen  says  further: 

"Beta-eucain  appears  to  present  no  advantage  over  cocain;  it  is 
equally  as  toxic,  much  less  anesthetic,  and  more  irritant. 

"Alypin  should  be  proscribed  in  view  of  its  toxicity  and  irritability 
qualities. 

'  New  Orleans  Med.  and  Surg.  Jour.,  October,  1913. 

'  J/Oc.  cit.  3  Jour.  Phys.  et  Path'gen. .'January,  1910. 


LOCAL  ANESTHETICS  111 

"Stovain  presents  considerable  advantage  over  cocain;  it  is  two  times 
less  toxic,  and  a  safe  dose  is  placed  at  30  eg.  of  a  1  to  200  solution. 

"The  irritant  action  following  its  use  and  its  weaker  anesthetic 
power  can  be  largely  overcome  by  using  it  in  normal  salt  solution  and 
in  slightly  greater  strength. 

"Novocain  appears  at  the  present  time  the  most  commendable  of 
local  anesthetics;  its  feeble  toxicity  permits  large  doses  to  be  used 
without  inconvenience;  it  has  considerable  anesthetic  power;  it  is  non- 
irritant  and  not  a  vasodilator.  The  only  inconvenience  is  that  its 
action  is  comparatively  a  little  shorter  than  cocain,  but  this  can  be 
overcome  by  the  addition  of  adrenalin,  which  produces  a  prolonged 
anesthesia  of  slightly  more  marked  degree  without  increasing  its 
toxicity." 

Methods  of  Administration. — Topical  Application. — For  anesthetiz- 
ing mucous  membranes  topical  application  may  be  used.  On  unbroken 
skin  the  local  anesthetic  has  no  effect.  For  this-  kind  of  an  anesthesia 
the  strength  of  the  solution  is  greater  than  that  used  for  other  methods. 
Cocain  is  generally  used,  although  Sollman^  says  that  beta-eucain, 
alypin  and  tropocain  are  very  useful.  A  5  per  cent,  solution  may  be 
used  for  local  application  to  the  mucous  membrane.  Epinephrin 
should  be  added  to  the  solution,  about  10  mimins  for  every  100  c.c.  of 
solution.  Care  must  be  exercised  in  its  use  in  the  urethra,  for  it  seems 
that  absorption  here  is  very  rapid.  In  nasal  work  the  strength  of  solu- 
tion should  be  1  per  cent,  with  the  adrenalin.  This  method  is  a  very 
excellent  one  as  a  preliminary  step  to  injection. 

Infiltration.— This  method  is  the  most  widely  used.  Necessary  for 
this  method  is  a  set  of  good  hj^odermic  needles  of  various  lengths 
and  a  good  syringe.  Many  syringes  have  been  invented,  such  as  self- 
filling,  those  that  deliver  the  solution  under  a  constant  pressure,  etc. 
But  a  convenient  apparatus  consists  of  a  s\Tinge  that  is  air-tight,  the 
size  varying  from  1  to  20  c.c,  and  several  h^-podermic  needles  of  various 
lengths. 

Reclus  first  introduced  this  method.  The  skin  should  be  injected 
first.  This  is  done  by  introducing  the  needle  into  the  skin  itself,  inject- 
ing the  solution  so  that  it  is  under  pressure  and  produces  wheals.  By 
pushing  the  needle  along  and  injecting  the  solution  at  a  constant  pres- 
sm-e  a  series  of  wheals  are  produced.  When  the  full  length  of  the  needle 
has  been  inserted,  withdraw  it  and  reinsert  it  in  the  skin  just  inside  of 
the  last  wheal  and  continue  the  injection.  If  the  operation  extends 
deeper,  by  means  of  a  larger  needle,  layer  by  layer  of  the  deeper  struc- 
tures are  injected,  so  that  all  the  structures  that  are  to  come  in  contact 
with  the  knife  are  anesthetized. 

Regional  Anesthesia;  Bier's  Intravenous  Anesthesia. — This  method 
was  introduced  by  Bier  in  1908.  It  is  applicable  to  operations  on  the 
limbs  when  infiltration  would  not  be  successful.    It  is  not  widely  used. 

The  limb  is  elevated  and  an  Esmarch  bandage  put  on,  beginning 

J  Jour.  Am.  Med.  Assn.,  January  26,  1918, 


112  ANESTHETICS  AND  ANESTHESIA 

at  the  distal  end  and  wound  proximally.  Above  this  bandage  a  tour- 
niquet is  appHed.  The  Esmarch  is  removed.  Another  tourniquet  is 
put  distal  to  where  the  operation  is  to  be  performed.  Into  the  veins, 
which  have  been  marked,  50  c.c.  of  a  j  to  ^  per  cent,  of  novocain 
solution  are  injected.  Anesthesia  will  be  quite  rapid,  but  one  must 
wait  until  the  field  of  operation  is  anesthetized.  There  may  be  a  motor 
paralysis  in  the  peripheral  part  of  the  limb,  but  that  soon  disappears. 
Bier  before  closing  the  wound  moves  the  peripheral  bandage  and  loosens 
the  proximal,  so  that  the  arteries  are  open,  but  the  veins  still  compressed. 
As  much  as  possible  of  the  solution  is  washed  out  of  the  wound.  If 
much  anesthetic  has  been  used  the  veins  can  be  washed  with  normal 
saline  and  a  good  deal  of  anesthetic  will  escape  through  the  wound. 
In  diabetes  and  arteriosclerosis  it  is  contra-indicated. 

Perineural  Method.— The  nerve  supplying  the  sensory  filaments  to 
the  area  which  is  to  be  operated  has  the  anesthetic  agent  infiltrated 
around  its  sheath.  This  in  from  ten  to  thirty  minutes  will  completely 
block  all  sensory  stimuli.  The  nerve  is  not  injured  and  this  is  a  simple 
method  of  procuring  anesthesia. 

Endoneural  Method. — Crile^  found  that  by  injecting  cocain  directly 
into  a  nerve  trunk,  anesthesia  of  the  part  supplied  by  the  nerve  quickly 
resulted.  In  promptness  it  has  the  advantage  over  the  perineural 
method,  but  it  can  only  be  used  in  large  nerves.  The  nerve  must  be 
exposed  to  be  certain  that  the  injection  is  made  into  the  nerve  itself. 
Sometimes  a  neuritis  follows  the  injection.  The  blocking  of  the  sensory 
stimuli  is  complete. 

Spinal  Anesthesia.^ — This  method  of  anesthesia  was  introduced  by 
Corning  in  1885.  Some  years  later  it  was  taken  up  by  Bier  and  made 
more  familiar  to  the  medical  profession.  Spinal  anesthesia,  as  all  other 
methods,  has  a  place  in  the  practice  of  medicine  and  surgery.  In  the 
hands  of  a  surgeon  who  has  had  experience  with  its  use  it  is  quite 
efficient.  Sometimes  in  the  hands  of  the  enthusiast  its  use  is  overdone. 
Oftentimes  in  attempting  this  method  of  anesthesia  a  partial  failure 
will  result  and  a  general  anesthetic  must  be  given. 

In  hypertension,  aneurysm,  cardiac  decompensation,  eclampsia, 
nephritis,  labor  and  arteriosclerosis  it  may  be  the  method  of  choice. 
Because  of  the  vasomotor  relaxation  it  is  contra-indicated  in  conditions 
of  h}T3otension.  In  operations  above  the  costal  arch,  superficial  infec- 
tion near  the  point  of  injection,  lesions  of  the  spinal  cord,  in  athletic 
individuals  and  for  light  anesthesia,  spinal  anesthesia  is  contra- 
indicated.  Care  and  good  judgment  must  be  used  in  the  selection  of 
patients  suitable  for  spinal  anesthesia. 

Attempts  have  been  made  to  regulate  the  height  of  the  anesthesia 
by  means  of  varying  the  specific  gravity  of  the  solution  injected.  A 
5  per  cent,  solution  of  glucose,  glucose  solution  with  alcohol,  using  spinal 
fluid  as  a  diluent,  have  been  employed.  At  the  present  time  the  5  per 
cent,  glucose  solution  is  used  much  more  abroad  while  the  tendency  in 
the  United  States  is  to  prefer  spinal  fluid. 

1  Jour.  Am.  Med.  Assn.,  February  22,  1902. 


LOCAL  ANESTHETICS  113 

Many  different  drugs  have  been  used,  cocain  being  the  first.  At 
the  present  time  most  of  them  have  been  discarded  with  the  exception 
of  stovain,  tropocain  and  novocain.  These  in  the  experience  of  men  who 
have  tested  spinal  anesthesia  mdely,  have  the  least  deleterious  effects. 
The  novocain  comes  in  what  is  kno^m  as  tablet  "A."  It  contains 
1|  grain  of  novocain  and  2T0"  grain  of  suprarenin. 

Orth  and  Miiller^  prepare  their  solution  in  the  folloA^ing  manner: 
An  ordinary  test-tube,  cork  to  stopper  and  beaker  are  boiled  fifteen 
minutes  in  water  free  from  bicarbonate  of  soda.  ■  They  specify  this 
because  novocain  and  adrenalin  preparations  are  chemically  affected 
by  alkalies.  These  utensils  are  then  rinsed  in  freshly  distilled  water. 
About  3  c.c.  of  freshly  distilled  water  are  poured  into  the  test-tube, 
boiled  a  few  minutes  and  allowed  to  stand  until  read}"  for  use.  A 
color  of  a  faint  rose  or  a  brownish  red  is  the  result  of  decomposition  of 
the  suprarenin  by  oxidation.  Only  clear  and  colorless  solutions  are  to 
be  used.  "When  ready  for  use  the  solution  is  brought  to  the  boiling- 
point  six  to  eight  times  to  sterilize.  It  is  not  boiled  continuously  as 
the  active  principle  of  suprarenin  would  thereby  lose  its  effect.  The 
solution  is  then  poured  into  the  beaker,  from  which  it  is  dra^m  into  a 
syringe.  The  specific  gravity  of  this  solution  is  approximately  that  of 
the  spinal  fluid,  l.OOS.  In  givmg  the  fluid,  about  7  c.c.  of  spinal  fluid 
are  withdraT\Ti  and  mixed  with  the  3  c.c.  of  novocain  solution  and  then 
slowly  injected. 

Barker-  uses  a  solution  isotonic  with  the  blood.  It  consists  by  weight, 
of  5  parts  of  stovam,  5  parts  of  glucose  and  90  parts  of  distilled  water. 
He  uses,  on  the  average,  1  c.c.  of  the  solution  and  injects  it  directly 
into  the  spinal  canal  mthout  withdrawing  any  spinal  fluid.  It  is  in- 
jected very  slowly.    Barker  does  not  use  adrenalin. 

The  site  of  injection  has  varied  from  between  the  fourth  and  fifth 
lumbar  to  high  in  the  dorsal  region.  At  the  present  time  high  injec- 
tions are  coming  more  and  more  into  disfavor,  and  only  the  low 
injections  in  the  region  of  the  lumbar  vertebrae  are  used.  It  is  less 
dangerous,  and,  if  a  higher  anesthesia  is  desired,  changing  the  position, 
using  more  solution  and  using  a  solution  of  low  specific  gravity  will 
give  it. 

Usually  the  region  between  the  tliird  and  fourth  lumbar  vertebrae 
is  chosen.  ^Miether  the  patient  sits  up  or  lies  down  depends  upon  the 
operator.  The  usual  way  is  for  the  patient  to  lie  on  the  side,  flex  the 
knees  on  the  abdomen  and  the  head  on  the  chest.  The  region  of  the 
back  is  prepared  with  the  usual  surgical  care.  The  needle  is  inserted 
in  the  midline  and  just  below  the  spine  of  the  third  lumbar  vertebra. 
The  needle  should  be  sharp,  the  bevel  on  the  end  short  and  the  diameter 
about  Y6  iiich  and  5  to  6  inches  long.  It  may  be  of  platinum  or  gold, 
as  they  are  flexible  and  stand  boiling  T^dthout  becoming  rusty.  The 
needle  with  the  stylet  is  introduced  until  it  suddenly  seems  to  go  easier. 
The  stylet  is  withdrawn  and  spinal  fluid  mil  usually  drop  out.    We 

1  A  Plea  for  Spinal  Anesthesia,  St.  Patil  Med.  Jour.,  July,  1917. 

2  Britisli  Med.  Jour.,  March  16,  1912. 


lU  ANESTHETICS  AND  ANESTHESIA 

are  now  in  the  subarachnoid  space  and  ready  to  withdraw  spinal  fluid 
to  mix  with  the  sohition. 

Anesthesia  begins  to  show  itself  very  soon  in  the  following  order: 
"Perineum,  external  genitalia,  posterior  surface  of  the  thighs,  legs,  feet, 
anterior  surface  of  the  thighs,  umbilicus  and  costal  arch."  (Orth  and 
Miiller.)  The  surgeon  must  be  careful  in  each  individual  case  to  see 
that  the  field  of  operation  is  fully  anesthetized  before  beginning.  The 
untoward  eft'ects  reported  are  many:  headaches,  ocular  palsies,  collapse, 
meningitis,  retention  of  urine,  chills,  elevation  of  temperature,  incon- 
tinence of  urine,  paraplegia,  pains  in  the  back  and  legs,  nausea,  vomit- 
ing, sweating,  dimness  of  vision  and  dyspnea.  These  are  unpleasant 
complications  and  can  be  obviated  to  a  great  degree,  (1)  by  using  a 
low  puncture;  (2)  by  injecting  the  solution  slowly,  so  as  to  permit 
rapid  absorption;  (3)  by  using  drugs  which  have  not  deteriorated. 
Orth  and  ]\Iuller^  found  that  headaches  and  the  untoward  effects  in  the 
use  of  no^■ocain  and  suprarenin  occurred  usually  when  the  solution 
was  reddish  or  brownish.  This  was  due  to  decomposition  of  the  supra- 
renin. They  also  insist  on  the  use  of  distilled  water  to  rule  out  any 
foreign  bodies. 

From  statistics  one  finds  that  spinal  anesthesia  has  a  fairly  high, 
mortality.  Tuffier-  notes  three  deaths  in  2000.  Perkins^  finds  in  a 
series  of  collected  cases  lb  deaths  in  2345  cases.  Although  in  special 
cases  it  may  be  the  anesthetic  of  choice,  it  cannot  compare  with  ether 
for  general  use.    It  should  be  undertaken  ^nly  by  men  of  experience. 

Paravertebral  Anesthesia. — To  circumvent  some  of  the  ill  effects  of 
special  anesthesia,  paravertebral  injection  of  the  spinal  nerves  has 
been  used.  Corning,  in  1885,  attempted  to  inject  close  to  the  spinal 
canal.  Selheim,  in  1905,  injected  the  roots  of  the  lower  dorsal  and  the 
ilio-inguinal  and  iliohypogastric  nerves.  The  solution  usually  used  is 
1  to  1^  per  cent,  novocain  with  adrenalin.  Some  observers,  especially 
Muroya,  use  a  5  per  cent,  gelatin  with  adrenalin  in  normal  s:Uine  to 
delay  absorption.  0.4  to  0.8  gm.  of  novocain  is  the  amount  that  is 
usually  needed. 

The  intervertebral  foramina  are  protected  by  the  lateral  projections 
of  the  transverse  processes.  As  the  anterior  and  posterior  roots  come 
out  of  the  intervertebral  foramina  they  join,  and  from  the  anterior 
branch  a  filament  runs  to  join  the  sympathetic  system.  The  object 
in  paravertebral  anesthesia  is  to  inject,  just  before  they  divide,  so  as 
to  catch  all  the  fibers.  After  determining  what  segments  are  to  be 
anesthetized,  these  segments  must  be  located  on  the  vertebral  column. 
After  definitely  locating  the  segments  one  is  ready  to  inject.  AUen^ 
gives  the  following  method  for  finding  the  point  of  injection:  "A 
vertical  line  is  drawn  down  the  tips  of  the  spinous  processes  and  lateral 
measurements  are  made  from  this  line;  the  free  intervals  between  the 

'  Loe.  cit. 

2  La  Presse  Medicale,  1901,  Iv,  190. 

3  New  Orleans  Med.  Jour.,  January-September,  1902. 
*  Local  Anesthesia,  1918,  2d  edition,  p.  494. 


LOCAL  ANESTHETICS  115 

transverse  processes  are  about  one  inch  on  each  side.  While  the  con- 
formation of  the  vertebrae  in  the  dorsal  and  lumbar  regions  is  quite 
different  this  measurement  holds  good  along  the  entire,  dorsal  and 
lumbar  regions.  As  the  intervertebral  foramina  are  shielded  posteriorly 
by  the  lateral  projections  of  the  articular  processes  a  point  about  J 
inch  farther  out,  making  1|  inch  from  the  midline,  is  best  selected 
as  the  point  of  puncture,  so  as  to  enable  the  needle  to  be  directed 
upward  and  inward  toward  the  intervertebral  foramina.  The  average 
interval  between  the  transverse  processes  in  the  dorsal  region  is  |  inch, 
while  the  midpoint  of  this  space  lies  in  a  vertical  line  about  1  inch  from 
the  midpoint  of  the  space  above  and  below  it. 

"  In  the  lumbar  region  the  free  space  between  the  transverse  processes 
is  from  i  to  f  inch  and  the  distance  from  the  midpoint  of  one  space 
to  that  of  another  is  IJ  inch." 

Untoward  effects  such  as  one  finds  in  spinal  anesthesia  have  been 
noted.  This  is  due  to  the  fact  that  while  injecting,  some  of  the  solu- 
tion enters  the  spinal  canal.  Lawen  and  Gaza,  in  experimenting  with 
epidural  injections  in  animals,  found  that  colored  solutions  entered  the 
spinal  canal  and  would  ascend,  so  that  care  must  be  exercised  while 
injecting.  The  injection  should  be  made  at  the  site  of  the  union 
of  the  anterior  and  posterior  branch  before  the  branch  to  the  sym- 
pathetic ganglia  is  given  off.  Too  much  pressure  should  not  be  exerted. 

This  method  is  used  also  in  the  cervical  region.  Braun,  following  the 
method  of  Heidenhain,  injected  in  a  line  drawn  from  the  transverse 
process  of  the  atlas  to  the  transverse  process  of  the  sixth  vertebra. 
By  inserting  the  needle  straight  in,  the  nerves  can  be  reached  and 
anesthesia  produced.  When  the  midline  structures  are  involved 
both  sides  of  the  neck  are  injected. 

Parasacral  Anesthesia.— Over  the  lower  end  of  the  sacrum,  just 
lateral  to  its  junction  with  the  coccyx,  a  long  needle  is  inserted.  This 
follows  up  the  sacrum  until  it  runs  into  the  lowest  sacral  foramen. 
As  the  needle  is  introduced  the  solution  is  slowly  injected.  As  each 
foramen  is  reached  more  solution  is  injected.  This  is  continued  until 
the  solution  has  been  injected  on  each  side.  Just  before  finishing, 
several  cubic  centimeters  are  injected  between  the  coccyx  and  the 
rectum.  This  injection  furnishes  a  sufficient  block  for  prostatectomies 
and  minor  operations  on  the  rectum.  Novocain  and  adrenalin,  ^  to 
1.05  per  cent,  is  used  in  making  this  injection. 


SHOCK  AND  HEMOEEHACIE. 


By  JOHN  W.  NUZUM,  B.S.,  M.D. 

Introduction. — The  importance  of  traumatic  shock  as  a  most  serious 
complication  attendant  on  a  certain  proportion  of  surgical  operations 
and  frequently  associated  with  various  wounds  and  injuries  of  the 
body,  has  led  to  an  extensive  investigation  of  the  mysterious  nature  of 
wound  shock  and  methods  of  combating  the  same. 

The  recent  world  war  has  afforded  unparalleled  opportunities  to 
surgeons  for  the  study  and  investigation  of  both  shock  and  hemorrhage. 
As  a  direct  result  several  of  the  older  conceptions  relative  to  the 
causation  of  shock  must  now  be  discarded  and  a  standardized  method  of 
treatment  has  been  definitely  established  on  a  sound  basis.  I  propose 
to  discuss  briefly  the  various  theories  of  the  etiology  of  shock,  together 
with  the  symptoms,  diagnosis,  prophylaxis  and  treatment. 

Definition. — Shock  may  be  defined  as  a  general  bodily  state  following 
various  surgical  operations  and  wounds  characterized  by  a  persistent 
low  arterial  blood-pressure,  rapid,  thready  pulse,  pallor,  sweating  and 
shallow,  rapid  respiration.  Primary  wound  shock  refers  to  those 
patients  in  w^hom  the  onset  of  the  typical  symptoms  occurs  suddenly, 
associated  with  the  constant  low  systolic  blood-pressure.  Secondary 
shock  is  confined  to  those  cases  in  whom  all  the  symptoms  of  shock 
manifest  themselves  only  after  a  longer  or  shorter  period  of  continu- 
ous hemorrhage,  exposure  to  cold,  complicating  infections,  etc.  All 
observers  agree  that  the  one  common  pathognomonic  finding  in  shock 
is  the  persistent  low  systolic  blood-pressure.  Hemorrhage  when  severe 
presents  a  clinical  picture  quite  similar  to  shock.  Dr.  W.  J.  Mayo,^ 
from  his  wide  surgical  experience  believes  that  perfect  hemostasis  is 
positive  prophylaxis  against  surgical  shock,  and  states  there  is  no 
surgical  shock  with  perfect  hemostasis. 

In  both  shock  and  hemorrhage  there  is  an  insufi5cient  circulation  of 
blood;  in  each  severe  damage  may  result  to  the  vital  cells  of  various 
essential  organs ;  and  in  both  conditions  the  essential  problem  is  the 
rapid  restoration  of  a  normal  blood-pressure.  It  is  common  knowledge 
that  shock  may  be  induced  by  rough  handling,  tearing  and  pulling  of 
the  body  tissues,  by  prolonged  exposure  of  the  abdominal  viscera,  by 
traumatism  to  the  mesentery  of  the  bowel  and  by  prolonged  anesthesia. 
Numerous  experimental  studies  of  shock  have  been  made  in  animals, 
apparently  with  the  view  of  discovering  a  single  cause  for  a  condition 
now  known  to  be  instituted  or  aggravated  by  a  variety  of  causes,  at 
least  in  man. 

1  Quoted  by  BisseU:     Surg.,  Gynec.  and  Obst.,  1917,  xxv,  8-22. 

(117) 


118  SHOCK  AND  HEMORRHAGE 

The  Critical  Level  of  Blood-pressure.— Fraser  and  CowelU  have 
reported  a  large  series  of  blood-pressure  determinations  made  in  shock 
cases  among  the  soldiers  in  France.  They  found  that  moderate  cases 
showed  a  systolic  pressure  of  approximately  90  mm.  of  mercury  while 
severely  shocked  patients  had  systolic  pressures  varying  from  40  to 
not  more  than  70  mm.  With  the  falling  arterial  pressure  it  is  very 
essential,  from  a  therapeutic  point  of  ^•iew,  to  know  at  what  level  in 
the  blood-pressure  scale  the  oxygen  supply  to  the  tissues  become 
insufficient.  It  has  been  found  that  this  'critical  level"  of  systolic 
pressure  is  approximately  80  mm.  of  mercury  and  a  fall  below  this  point 
maintained  for  any  considerable  time  results  in  an  inadequate  oxygen 
supply  to  the  tissues.  The  nerve  cells  are  early  affected  by  this  anemia; 
later  the  vasomotor  mechanism  suffers,  and  if  the  arterial  pressure  is 
not  restored  before  too  long  a  lapse  of  time  no  known  treatment  will 
suffice  to  save  the  patient's  life. 

Theories  of  Etiology  of  Shock.^iV^'n'e  Exhaustion  Theory.^G.  W. 
Crile,-  as  a  result  of  extensive  investigations  of  the  blood-pressure  and 
nerve  cells  in  shocked  animals,  states  that  "the  most  vital  effect  of 
shock  is  the  impairment  of  the  vasomotor  mechanism."  He  believes 
that  exhaustion  of  the  cells  in  the  brain,  liver  and  suprarenal  glands 
constitutes  shock,  Crile^  and  Dolley  have  shown  that  histological 
changes  can  be  demonstrated  in  the  nerve  cells  of  shocked  animals, 
which  they  attribute  to  the  afferent  impulses  reaching  the  nerve 
cells  from  stimuli  induced  by  trauma,  fear,  emotions,  etc.  On  this 
basis  Crile  has  developed  his  theory  of  anoci-association  or  nerve-block- 
ing, wuth  which  all  surgeons  are  familiar.  It  should  be  stated  that 
those  wdio  dispute  the  evidence  of  histological  changes  in  the  nerve 
cells  of  shocked  animals  claim  that  similar  histological  changes  are 
within  the  limits  of  normal  variations,''  and  that  these  same  alterations 
in  the  nerve  cells  are  the  result  of  low  blood-pressure  rather  than  its 
cause.* 

The  Acapnia  Theory. — ^Henderson^  advanced  the  theory  that  shock 
was  the  result  of  a  reduction  of  the  carbon-dioxide  of  the  blood,  a 
condition  known  as  acapnia.  In  support  of  his  argument  he  produced 
a  shock-like  state  in  animals  by  vigorous  artificial  respiration.  He 
believed  that  the  diminished  CO2  content  of  the  blood  produced  in 
the  above  manner  was  the  prime  factor  in  the  production  of  shock. 

Fat  Embolism. — Porter,  who  was  one  of  the  first  Americans  to  visit 
the  battlefields  of  France  in  order  to  study  shock  in  the  front-line 
trenches,  has  brought  evidence  to  show  that  shock  may  be  produced 

1  A  Clinical  Study  of  Blood-pressure  in  Wound  Conditions,  Jour.  Am.  Med.  Assn., 
1918,  p.  520. 

2  Volumes  on  Surgical  Shock;  Blood-pressure  in  Surgery;  Anoci-association. 
'  Anoci-association,  Philadelphia,  1913. 

<  Allen:  Proc.  Soc.  Exper.  Biol,  and  Med.,  1915,  xii,  96:  Kocher,  R.  A.:  The 
Effect  of  Acti\aty  on  the  Histological  Structure  of  Nerve  Cells,  Jour.  Am.  Med.  Assn. 
July  22,  1916,  p.  278. 

» Cannon,  W.  B.:  A  Consideration  of  the  Nature  of  Wound  Shock,  .lour.  Am.  Med. 
Assn.,   March  2,   1917,  pp.   611-617. 

«  Am.  Jour.  Physiol.,  A  Series  of  Papers,  1908-1910. 


THEORIES  OF  ETIOLOGY  OF  SHOCK  119 

in  animals  by  the  intravascular  injection  of  fat  or  oil.  In  his  paper 
on  "Shock  at  the  Front"^  he  wrote  as  follows:  "I  have  myself  ex- 
amined more  than  a  thousand  wounded.  Save  a  few  wounds  of  the 
abdomen,  in  which  the  bloodvessels  or  their  nerves  in  that  great 
vascular  region  were  probably  directly  injured,  there  has  been  no  case 
of  shock  except  after  shell  fractures  of  the  thigh,  and  after  multiple 
wounds  through  the  subcutaneous  fat.  In  these,  closure  of  the  capil- 
laries by  fat  globules  is  known  to  take  place.  This  is  strong  support 
for  my  discovery  that  shock  may  be  produced  in  animals  by  injecting 
fat  into  the  veins." 

Porter  advocated  the  rebreathing  of  expired  air  as  a  preliminary 
measure  to  improve  the  circulation  before  surgical  operations  in  badly 
shocked  soldiers.  His  plan  was  to  increase  the  excursions  of  the 
diaphragm  so  as  to  pump  the  blood  out  of  the  great  splanchnic  vessels 
back  into  the  heart. 

BisselP  has  observed  six  instances  of  fatal  postoperative  fat  embolism 
in  the  necropsy  service  of  the  Mayo  Clinic,  and  concludes  that  "deaths 
clinically  supposed  to  be  due  to  surgical  shock  are  due,  in  so  far  as  this 
experience  goes,  to  pulmonary  fat  embolism  and  its  attendant  blood- 
pressure  phenomena." 

Several  investigations  have  brought  forward  evidence  to  disprove 
the  fat-embolism  theory  of  shock,  and  have  pointed  out  a  possible 
danger  in  the  rebreathing  of  expired  air  as  advocated  by  Porter.  Thus, 
Cannon^  quotes:  "English  surgeons  of  extensive  experience  at  casualty 
clearing  stations  in  the  recent  war,  who  have  performed  many  hundreds 
of  abdominal  operations  on  patients  in  all  degrees  of  wound  shock, 
have  testified  that  on  opening  the  abdomen  they  have  not  found  any 
primary  splanchnic  congestion." 

Furthermore,  as  regards  the  possible  dangers  of  rebreathing  expired 
air,  "The  testimony  of  Marshall,  who  as  an  expert  anesthetist  in  a 
casualty  clearing  station  has  had  large  experience,  is  pertinent  .  .  . 
the  most  important  consideration  in  anesthetizing  patients  suffering 
from  hemorrhage  or  shock  is  to  atoid  anything  in  the  nature  of  asphyxia; 
indeed,  that  if  such  a  patient  becomes  cyanosed  he  loses  ground  that 
can  hardly  be  recovered . " 

Finally,  McKibben^  reports  the  presence  of  fat  in  the  vessels  of  all 
animals  examined  whether  shocked  or  not  and  no  quantitative  or  quali- 
tative differences  were  noted  between  the  fat  in  the  vessels  of  shocked 
animals  and  those  of  normal  animals. 

Suprarenal  Exhaustion. — It  is  known  that  the  medullary  portions 
of  the  suprarenal  bodies  possess  a  blood-pressure-raising  constituent, 
and  the  theory  has  been  advanced  that  exhaustion  of  the  glands  leads 
to  shock  with  consequent  low  blood-pressure.    As  opposed  to  this 

1  Shock  at  the  Front,  Boston,  1918. 

2  Pulmonary  Fat  Embolism:  A  Frequent  Cause  of  Postoperative  Surgical  Shock, 
Surg.,  Gynec.  and  Obst.,  1917,  xxv,  8-22. 

^  Statement  by  Wallace,  Fraser  and  Drummond:     Lancet,  London,  1917,  ii,  727. 
*  A  Note  on  Intravascular  Fat  in  Relation  to  the  Experimental  Study  of  Fat  Embo- 
Hsm  in  Shell  Shock,  Am.  Jour.  Physiol.,  1919,  xlviii,  331. 


120  SHOCK  AND  HEMORRHAdK 

theory,  Mann'  has  shown  that  total  suprarenalectomy  does  not  pro- 
duce the  state  of  shock. 

The  Cardiac  Failure  Theory. — Arjijiiments  that  the  heart  itself  is 
the  ofl'ending  organ  in  shock  wonid  seem  to  be  disproved  by  the 
repeated  observations  on  the  slowing  of  the  ra{)id  heart  action  and  the 
resumption  of  its  normal  function  following  massive  transfusion  of 
blood  in  patients  suffering  from  shock  due  to  hemorrhage. 

Shock  as  Exemia. — After  an  intensive  study  of  shocked  troops 
on  the  battlefields,  Cannon-  offers  an  additional  conception  of 
the  causation  of  shock  which  demands  critical  analysis.  He  believes 
that  the  low  blood-pressure  of  shock  is  explicable  as  a  consequence  of 
blood  being  stagnant  in  some  part  of  the  vascular  system,  a  condition 
to  which  he  has  given  the  name  of  "exemia,"  meaning  "drained  off 
blood."  This  exemic  blood  is  not  in  the  abdominal  veins  as  formerly 
supposed,  but  is  stagnant  in  the  capillary  beds.  He  has  demonstrated 
that  the  capillary  blood  in  shock  may  be  so  concentrated  that  a  cubic 
millimeter  by  actual  count  may  contain  as  high  as  two  and  one-half 
million  more  of  red  blood  cells  than  simultaneous  venous  blood  counts. 

Furthermore,  in  cooperation  with  Bayliss,  Cannon  has  shown  that 
shock  may  result  from  tissue  injury.  Thus  "  the  crushing  of  the  muscles 
of  the  hind  leg  of  an  animal  is  followed  by  a  fall  of  arterial  pressure 
reaching  a  shock  level  in  about  one  hour.  This  effect  occurs  even 
though  the  nerves  to  the  leg  are  severed ;  it  is  therefore  not  of  nervous 
origin.  If  the  bloodvessels  (iliac  artery  and  vein)  of  the  leg  are  tied 
and  the  muscles  injured  by  blows  the  pressure  drops  only  after  the 
blood  flow  is  restored.  And  if  a  shock  pressure  is  produced  by  muscle 
injury,  tying  the  vessels  may  be  followed  by  a  steady  rise  of  arterial 
pressure  to  the  normal  level." 

As  a  result  of  these  important  observations,  Cannon  has  arrived  at 
the  following  conception  of  wound  shock:  "There  are  primary  wound 
shock  with  rapid  lowering  of  arterial  pressure,  and  secondary  wound 
shock  with  toxemia  and  hemorrhage  and  subsequent  lowering  of  the 
pressure." 

Various  causes  in  combination,  some  nervous,  others  chemical  and 
each  associated  with  a  reduction  of  arterial  pressure,  and  all  exag- 
gerated by  hemorrhage,  result  in  a  state  of  collapse  attended  by  a  low 
blood-pressure.  Sweating  occurs  with  loss  of  fluids  and  loss  of  body 
heat.  Along  with  hemorrhage,  absorption  of  the  toxic  products  con- 
tained in  the  tissue  juices  of  the  injured  muscles  effect  a  concentration 
and  stagnation  of  the  blood  in  the  capillary  beds.  With  the  fall  of 
pressure  acidosis  supervenes  roughly  proportionate  to  the  drop  of 
pressure. 

The  condition  of  the  shocked  man  tends  to  become  acute  unless  the 
absorption  of  the  toxic  products  of  muscle  injury  are  counteracted. 

'  Shock  during  General  Anesthesia,  Jour.  Am.  Med.  Assn.,  August  4,  1917,  p.  371. 

2  A  Consideration  of  the  Nature  of  Wound  Shock,  Jour.  Am.  Med.  Assn.,  March  2, 
1918,  pp.  611-617.  Reports  of  Special  Shock  Investigation  Committee  of  the  Medical 
Research  Committee  of  Great  Britain — a  series  of  six  papers. 


PROPHYLACTIC   TREAT  ME  ST  OF  SHOCK  121 

Operative  treatment  is  imperative  at  the  earliest  possible  moment.  A 
shattered,  useless  limb  must  be  amputated.  A  tourniquet  should  be 
applied  as  near  as  possible  to  the  zone  of  injury  and  amputation  done 
proximal  to  the  constrictor  before  removal  of  the  same.  It  is  vital 
that  the  blood  volume  and  blood-pressure  be  raised  above  the  critical 
level  by  transfusion  before  the  existing  anemia  of  the  nerve  centers 
leads  to  a  permanent  paralysis.  After  too  long  a  period  of  anemia 
recovery  is  not  possible  by  any  kno-^m  method  of  treatment. 

It  is  obvious,  from  the  many  diverse  theories  on  the  causation  of 
shock  and  the  voluminous  literature  relative  to  experimental  produc- 
tion of  shock  and  its  clinical  manifestations,  that  the  real  etiological 
factors  still  remain  to  be  discovered.  However,  it  must  be  admitted 
that  vital  information,  more  especially  as  regards  treatment  and 
prophylaxis,  has  accrued  from  the  careful  and  tedious  investigations 
made  during  the  recent  world  war.  Fat  embolism  does  not  explain  all 
of  the  cases;  loss  of  vasomotor  control  with  stagnation  of  blood  in 
the  great  splanchnic  vessels,  a  theory  which  had  gained  considerable 
prominence,  could  not  be  confirmed  by  English  surgeons  performing 
many  hundreds  of  abdominal  sections  on  soldiers  in  all  stages  of  wound 
shock;  while  Cannon's  notion  of  stasis  of  blood  in  the  capillary  bed 
with  toxic  absorption  of  the  products  of  injured  muscle  tissue  has  yet 
to  be  confirmed. 

It  seems  fair  to  assume  that  each  of  these  different  factors  may  play 
a  role  in  certain  cases  of  shock,  some  instigating,  others  merely  the 
result  of  a  state  of  traumatic  or  surgical  shock. 

Diagnosis. — The  diagnosis  of  surgical  shock  calls  for  but  brief 
comment.  Indeed,  surgeons  with  but  limited  experience,  if  alert, 
recognize  the  t%'pical  syndrome  in  its  early  stages  when  appropriate 
treatment  can  be  best  instituted.  The  characteristic  pallor,  sweating, 
rapid  weak  pulse,  subnormal  temperature,  shallow  rapid  breath- 
ing and  a  falling  blood-pressure  constitute  a  clinical  picture  which 
can  hardly  be  misinterpreted.  When  the  condition  develops  subse- 
quent to  a  prolonged  or  severe  operation,  or  supervenes  rapidly  after 
a  severe  hemorrhage,  the  diagnosis  is  evident  and  the  indications  for 
treatment  are  both  definite  and  urgent. 

Hemorrhage. — Severe  hemorrhage  must  be  differentiated  from  shock, 
although  the  differential  diagnosis  is  of  little  moment,  because  the 
treatment  of  both  conditions  is  identical  and  because  a  hemorrhage 
so  often  instigates  the  shock  state.  In  sudden,  severe  hemorrhage,  as 
when  a  large  artery  is  severed,  the  skin  becomes  cold,  clammy  and  pale, 
the  respirations  are  gasping  and  the  temperature  of  the  body  sub- 
normal. The  body  tissues  suffer  from  anemia,  the  patient  often  com- 
plains of  a  sensation  of  suffocation  (air  hunger)  and  becomes  extremely 
restless.  The  pulse  is  very  rapid  and  weak  and  death  quickly  ensues. 
During  the  hemorrhage  the  blood-pressure  rapidly  falls  below  the 
so-called  "critical  level." 

Prophylactic  Treatment  of  Shock. — For  many  years  Dr.  A.  J.  Ochsner 
has  insisted  that  careful  attention  to  details,  namely,  avoidance  of 


122  SHOCK  AND  HEMORRHAGE 

exposure  of  the  body  to  cold,  gentle  manipulation  of  tissues,  clean, 
sharp  dissection,  nerve-blocking  by  Crile's  method,  careful  hemostasis, 
etc.,  are  little  things  of  big  moment  to  the  patient.  INlinor  details, 
such  as  avoiding  useless  trauma  to  tissues  occasioned  by  the  prolonged 
pull  of  retractors,  preliminary  elevation  of  the  foot  of  the  operating 
table  to  facilitate  gravitation  of  the  small  bowel  upward  out  of  the 
operative  field  in  pelvic  operations,  elevation  of  the  head  of  the  table 
to  prolong  cerebral  anemia  and  diminish  the  amount  of  ether  required 
in  thyroidectomies,  all  of  these  seemingly  insignificant  details  serve  to 
increase  the  margin  of  safety  for  the  patient. 

Treatment. — There  is  abundant  evidence  to  prove  conclusively  that 
exposure  to  cold  has  a  very  marked  effect  on  instigating  and  increasing 
the  state  of  shock.  Accordingly^  every  effort  must  be  made  to  restore 
the  body  heat  to  the  normal  temperature.  Avoid  exposure  of  the  body. 
Apply  external  heat  by  means  of  hot-water  bottles.  Wrap  the  patient 
in  warm  blankets.  Administer  hot  drinks  to  restore  the  body  fluids 
and  increase  the  blood  volume.  ]\Iorphin  should  be  given  in  large 
enough  doses  to  keep  the  patient  quiet.  The  systolic  blood-pressure 
readings  are  usually  low.  With  a  systolic  pressiu-e  below  the  "  critical 
level,"  namely,  80  to  90  mm.  of  mercury,  a  blood  transfusion  should  be 
instituted  without  delay.  It  is  common  knowledge  that  blood  trans- 
fusion is  the  specific  treatment  for  shock  secondary  to  hemorrhage  and 
the  clinical  improvement  is  both  rapid  and  certain,  provided  the 
oxygen  deficiency  of  the  tissues  has  not  existed  for  too  long  a  time.  A 
small  percentage  of  patients  will  require  repeated  transfusions  if  the 
blood  loss  has  been  severe. 

Transfusion  of  blood  is  indicated  in  patients  who  have  lost  con- 
siderable blood  during  a  prolonged  or  severe  operation  in  whom  the 
blood-pressure  tends  to  remain  low  in  spite  of  supporting  treatment. 
Cases  of  secondary  anemia,  with  suppurating  wounds  and  sinuses, 
often  make  a  rapid  convalescence  after  repeated  transfusions.  For 
several  years  it  has  been  the  practice  at  the  Augustana  Hospital  to 
group  the  blood  of  a  large  number  of  available  individuals  in  good 
health  who  have  a  negative  Wassermann  test  and  are  desirous  of 
giving  their  blood  for  a  small  fee.  In  this  way  donors  properly  grouped 
are  always  available  for  any  emergency.  The  technic  employed  is  the 
massive  transfusion  of  whole  blood  by  means  of  Dr.  Percy's  modi- 
fication of  the  Kimpton  paraffin  tube  method.  Amounts  of  blood 
varying  from  500  to  1000  c.c.  can  be  transfused  within  a  period  of 
h\e  to  six  minutes.  This  method  has  been  shown  to  yield  a  smaller 
percentage  of  reactions  than  the  citrate  method  and  possesses  the 
additional  advantage  that  the  patient  receives  the  blood  without  the 
addition  of  any  chemical  agent  in  as  near  the  normal  state  as  possible. 
The  technical  details  o*  this  method  are  discussed  by  Dr.  Percy  in 
another  chapter.  It  should  be  emphasized  at  this  point,  that  the 
splendid  clinical  results  obtained  by  blood  transfusion  therapy  in 
thousands  of  soldiers  suffering  from  shock  and  hemorrhage,  with 
an  enormous  saving  of  lives,  has  established  this  method  of  treatment 
on  a  sound  and  popular  basis. 


SUMMARY    METHODS  FOR  COMBATING  SURGICAL  SHOCK       123 

Bayliss^  has  introduced  the  infusion  of  a  6  per  cent,  solution  of  gum 
acacia  in  0.9  per  cent,  sodium  chloride  as  a  substitute  for  blood  trans- 
fusion when  blood  is  not  available  in  sufficient  quantities.  He  advo- 
cates infusion  of  500  c.c.  amounts  by  the  intravenous  route  within  a 
period  of  twenty  minutes.  This  solution  has  the  advantage  over  normal 
salt  and  adrenalin  infusions,  in  that  it  does  not  leave  the  bloodvessels 
rapidly  and  it  restores  the  blood-pressure  by  increasing  the  total  blood 
volume.  It  has  the  disadvantage  that,  unlike  blood,  the  oxygen  carriers 
or  red  blood  cells  are  not  increased  by  this  solution.  However,  surgeons 
who  have  had  experience  with  the  giun-salt  infusion  method  report 
that  fatalities  were  not  uncommon  some  of  which  must  be  attributed 
to  the  solution.  As  regards  the  use  of  various  drugs,  namely,  strychnin, 
camphorated  oil,  etc.,  little  need  be  said  except  to  point  out  that  their 
effect  at  best  is  very  transitory  and  there  is  probably  very  little  to 
commend  them. 


SURGICAL  OPERATIONS  IN  RELATION  TO  SHOCK. 

Finally,  we  come  to  a  consideration  of  the  treatment  of  those  cases 
of  shock  in  whom  injuries  or  disease  demand  surgical  procedures  as  a 
life-saving  measure.  It  is  well  known  that  operations  on  patients  in 
the  shock  state  or  those  who  have  recently  recovered  from  a  severe 
hemorrhage  are  attended  by  grave  dangers,  due  primarily  to  the  low 
blood-pressure.  These  cases  do  not  stand  ether  anesthesia  well. 
Clinical  observations  have  demonstrated  that  the  anesthetic  of  choice 
is  nitrous  oxide  and  oxygen  in  the  ratio  of  three  parts  of  nitrous  oxide 
to  one  part  of  oxygen.  Morphin  should  be  given  before  operation,  and 
great  care  is  essential  that  cyanosis  and  deep  anesthesia  be  absolutely 
avoided,  as  they  precipitate  an  additional  fall  in  an  already  low  blood- 
pressure.  Exactly  the  same  precautions  relative  to  the  gentle  handling 
of  tissues,  avoidance  of  exposure  to  cold,  etc.,  apply  here.  If  ampu- 
tation of  an  extremity  is  imperative  a  tourniquet  should  be  applied 
proximal  to  the  lesion  and  removed  only  after  the  amputation  has 
been  completed. 

SUMMARY  OF  METHODS  FOR  COMBATING  SURGICAL  SHOCK. 

For  those  patients  in  the  shock  state  who  demand  surgical  treatment 
as  a  life-saving  measure  the  following  suggestions  are  pertinent: 

1.  The  anesthetic  of  choice  is  nitrous-oxide-oxygen  gas.  It  should 
be  administered  by  a  skilled  anesthetist  and  great  care  taken  to  avoid 
cyanosis. 

2.  Avoid  unnecessary  exposure  of  the  patient's  body  during  oper- 
ation. All  surgical  manipulations  must  be  conducted  with  the  greatest 
degree  of  gentleness  and  care  must  be  exercised  to  avoid  those  factors 
which  precipitate  or  aggravate  the  general  shock  state,  viz.,  rough 

*  Intravenous  Injection  in  Wound  Shock,  London,  1918. 


124  SHOCK  AND  HEMORRHAGE 

handling  oF  tissues,  ijrolonged  exposure  of  the  bowel  or  other  viscera, 
needless  handling  of  the  intestines,  pulling  on  the  mesentery,  etc.  It 
goes  without  saying  that  all  surgical  i)r()ce(lures  should  be  conducted 
as  rapidly  as  is  consistent  with  good  surgery. 

3.  Transfusion  of  blood  is  specific  for  the  treatment  of  shock  second- 
ary to.^'el-e  hemorrhage.  There  is  also  good  reason  for  believing 
that  tran^usion  of  whole  blood  may  act  as  a  i)r()i)hylactic  against  the 
development  of  shock  in  patients  subjected  to  prolonged  or  severe 
operations.  Certain  it  is  that  patients  respond  in  a  most  striking  and 
beneficial  manner  after  a  transfusion  performed  either  during  or  at 
the  completion  of  such  an  operation. 

4.  Postoperative  care  of  the  shock  patient  demands  the  application 
of  external  heat.  The  body  should  be  wrapped  in  warm  woollen 
blankets.  Hot-water  bottles,  carefully  protected,  should  be  applied 
to  the  patient's  body.    Hot  drinks  may  be  given  by  mouth. 

5.  The  blood-pressure  and  blood  vokmie  must  be  restored.  Saline 
hj-podermoclysis  is  often  a  valuable  adjunct  when  transfusion  is  not 
possible. 

6.  The  more  common  drugs  employed  to  combat  shock,  such  as 
strychnin,  camphorated  oil,  adrenalin  solution,  etc.,  all  have  the  prac- 
tical objection  that  their  action  is  at  best  but  transitory.  ^lorphin 
by  h^TDodermic  injection  is  of  definite  value  in  many  cases.  It 
diminishes  the  amount  of  anesthetic  required  and  subdues  the  use- 
less muscular  exertions  of  the  restless  patient.  It  blocks  the  passage 
of  external  pain  stimuli  to  the  higher  cerebral  centers. 


I\FLA3DIATI0X  AXD  HEALIXG  OF  WOODS. 


By  JOHN  W.  XUZOI,  B.S.,  M.D. 

Definition. — Inflammation  may  be  defined  as  the  series  of  phenomena 
which  follow  local  injtiry  to  the  tissues  of  the  body.  It  is  a  complex 
vascular  and  cellular  response  on  the  part  of  the  tissues  involved, 
whereby  the  blood  serimi  and  blood  corpuscles  are  mobilized  at  the 
site  of  injtny  in  order  to  engage  and  destroy  the  invading  bacteria, 
overcome  the  infection,  aid  in  removing  the  inflammatory  debris 
and  ultimately  prepare  the  field  for  reparative  processes  of  healing. 

Sir  John  Sanderson  defined  inflammation  as  "the  succession  of 
changes  which  occur  in  a  living  tissue  when  it  is  injiu"ed,  provided  that 
injtu-y  is  not  of  such  a  degree  as  at  once  to  destroy  its  structure  and 
vitality."  Professor  Adami's  definition  is  as  follows:  ''The  series  of 
changes  constituting  the  local  manifestation  of  the  attempt  at  repair 
of  actual  or  referred  injury  to  a  part  or  briefly  the  local  attempt  at 
repair  of  actual  or  referred  injury."'" 

Formerly  inflammation  was  considered  by  pathologists  as  a  destruc- 
ti\"e  and  harmful  process,  but  subsequent  bacteriological  studies  haA'e 
proved  concltisively  that  the  tissue  response  in  inflammation  is  largely 
of  a  protective  nature  and  represents  the  body  defences  against  invasion 
by  various  microorganisms.  It  should  be  clearly  understood  that 
repair  goes  hand-m-hand  with  inflammation  and  constitutes  the  end- 
picttu-e  of  the  phenomenon. 

Etiology. — The  causes  are  both  nimierous  and  varied,  and  may  be 
subdivided  mto: 

(a)  Predis'pQsing  causes,  such  as  general  debility,  senility,  cardiac 
and  renal  disease,  SA'philis,  gout,  rheiunatism,  tuberculosis  or  infectious 
diseases  in  general,  all  tending  to  lower  the  normal  bodily  resistance. 

(h)  Exciting  causes  are  injmies  and  infections.  Accordingly  the 
inflammatory  irritants  ma>'  be  classified  as  mechanical,  such  as  wounds 
or  contusions  of  the  body;  chemical,  such  as  burns  by  acids  or  alkalies; 
thermal,  as  exposure  to  the  rays  of  the  sun  (dermatitis  solare  or  sim- 
burn);  freezing  the  exposed  parts  of  the  body;  and  specific  inflam- 
mations of  the  tissues  as,  for  example,  erysipelas  which  is  caused  by  the 
presence  of  the  streptococcus  in  the  subcutaneous  hTQphatics.  Some 
authors  believe  that  all  inflammatory  processes  are  the  result  of 
microorganisms  or  the  toxins  produced  by  the  bacteria  which  lead  to 
necrosis  of  the  tissue  cells  of  the  host.  However,  it  would  seem  that 
while  bacteria  probably  are  responsible  for  the  greater  nimiber  of 
inflammatory  processes,  such  is  not  always  the  case. 

( 125 ) 


120  INFLAMMATION  AND  HEALING  OF   WOUNDS 

Pathology  of  Inflammation. — Tlic  patli()lo<>y  of  acute  iiiflainmation 
may  be  conveniently  considered  under  the  following  heads,  viz.:  (1) 
circulatory  changes;  (2)  migration  of  blood  corpuscles  and  fluids  into 
the  tissues;  (3)  changes  in  the  perivascular  tissues.  When  pathogenic 
staphylococci  gain  access  to  the  deeper  tissues  of  the  body  and  are 
able  to  multiply  in  sufficient  numbers  to  set  up  an  acute  inflaTnmatory 
reaction  the  process  may  be  described  as  follows: 

1 .  The  circulatory  changes  consist  of  a  transitory  contraction  of  the 
bloodvessels  of  the  afl'ected  part  followed  by  a  dilatation  of  the  vessels 
with  an  acceleration  of  the  velocity  of  the  blood  stream  (active  hyper- 
emia) .  Later  the  blood  stream  becomes  slower  and  eventually  an  actual 
stagnation  of  the  blood  current  results  in  a  condition  of  passive  hyper- 
emia. With  the  slowing  of  the  blood  the  leukocytes  tend  to  separate 
from  the  central  or  axial  stream  and  come  to  roll  along  and  accimiulate 
against  the  walls  of  the  bloodvessels  (margination).  The  leukocytes 
and  platelets  tend  to  associate  at  the  periphery  while  the  red  cells  gain 
the  axial  portion  of  the  blood  stream. 

2.  Exudation,  or  the  passage  of  the  constituents  of  the  blood  through 
the  vessel  walls,  begins  as  soon  as  a  passive  hyperemia  has  been 
established.  The  polymorphonuclear  leukocytes  insinuate  their  pseudo- 
podia  between  the  endothelial  cells  lining  the  vessels  and  rapidly 
worm  their  way  through  the  vessel  walls  to  gain  access  to  the  adjacent 
perivascular  tissues  in  large  numbers.  The  plasma  of  the  blood 
passes  into  the  surrounding  tissues  in  excess  of  the  amount  required 
to  nourish  the  tissue  cells,  and  since  it  is  not  carried  away  sufficiently 
rapid  by  the  lymphatics,  an  inflammatory  edema  results.  The  red 
cells  and  blood  platelets,  lacking  ameboid  movements,  are  carried 
through  the  vessel  walls  by  diapedesis.  Finally,  there  is  a  marked 
increase  in  the  total  nimiber  of  the  leukocytes,  both  in  the  inflammatory 
zone  and  also  in  the  general  blood  stream  (leukocytosis). 

3.  Changes  in  the  Perivascular  Tissues. — With  the  myriads  oi 
leukocytes  mobilized  in  the  zone  of  inflammation  the  combat  for 
supremacy  ensues  between  the  invading  bacteria  and  the  defensive 
white  blood  corpuscles.  Many  of  the  polymorphonuclear  leukocytes 
exert  a  phagocytic  function  engulfing  the  bacteria  and  destroying 
them  while  others  are  disintegrated  and  liberate  thrombokinase,  which 
acts  on  the  fluid  present  in  the  tissues  to  form  the  delicate  meshwork. 
The  leukocytes  perform  additional  important  service,  not  alone  destroy- 
ing the  invading  microorganisms  but  acting  as  scavengers  they  digest 
the  dead  tissues  and  pass  back  into  the  circulation  through  the 
lymphatics;  if  suppuration  ensues  they  become  pus  cells.  At  the  same 
time  the  liquor  sanguinis  present  in  the  tissues  at  the  site  of  injury  pos- 
sesses both  bactericidal  and  antitoxic  properties  against  the  bacterial 
invaders.  Finally,  the  area  is  cleaned  of  debris,  the  fibroblasts  pro- 
liferate to  form  new  connective  tissue,  new  capillaries  develop  to 
vascularize  the  newly  formed  connective  tissue  and  healing  may  be 
said  to  be  well  advanced.  Thus  it  seems  that  acute  inflammation  repre- 
sents a  protective  process  whereby  Nature  pours  large  numbers  of 


VARIETIES  OF  INFLAMMATION  127 

cells  and  quantities  of  fluid  into  the  inflammatory  zone  to  meet  and 
destroy  invading  microorganisms,  neutralize  bacterial  toxins  and 
furnish  digestive  ferments  to  liquefy  and  facilitate  disposal  of  the 
inflammatory  debris. 

VARIETIES  OF  INFLAMMATION. 

Varieties  of  inflammation  may  be  subdivided  into  acute  forms,  with 
sudden  onset  and  severe  course;  subacute,  with  insidious  onset  and 
milder  t\'pe  and  chronic  inflammation  of  low  grade  and  long  duration. 

Parenchymatous  refers  to  involvement  of  the  parench\TQa  or  secret- 
ing cells  of  an  infected  organ  as  contrasted  with  interstitial  inflam- 
mation where  the  connective-tissue  cells  are  affected.  Traumatic, 
due  to  an  injury;  specific  infective,  due  to  various  microorganisms; 
serous,  with  profuse  serous  exudation;  'purulent  or  suppurative ,  char- 
acterized by  excess  of  pus;  hemorrhagic,  associated  with  bloody  exu- 
date; catarrhal,  as  in  inflammation  of  mucous  membranes;  pseudo- 
memhranous,  characterized  by  the  presence  of  a  false  membrane  formed 
from  the  tissues  rather  than  from  the  exudate;  gangrenous,  with 
necrotic  foul-smelling  exudation;  metastatic,  as  in  inflammation  at  a 
distant  point  from  the  original  focus  through  blood-stream  dissemi- 
nation, etc. 

Symptomatology. — The  local  s^Tuptoms  are  pain  (dolor),  heat, 
(calor),  redness  (rubor),  swelling  (tumor),  and  disturbance  of  function 
(functio  laesa). 

Pain  of  acute  inflammation  is  of  slow  onset,  constantly  present  in 
the  same  location,  and  is  increased  by  palpation  of  the  aftected  area  or 
by  allowing  the  part  to  be  placed  in  a  dependent  position.  This  pain 
is  due  to  the  pressure  of  the  inflammatory  exudate  on  the  terminal 
nerve  endings  and  probably  also  to  the  tissue  changes  resulting  from 
the  presence  of  bacterial  toxins.  Heat  is  due  to  the  increased  amount 
of  blood  brought  to  the  aft'ected  part.  Redness  is  due  to  the  increased 
blood  content.  In  acute  inflammation  the  skin  may  be  a  livid  scarlet 
red  but  with  older  cases  it  fades  into  a  dusky  purple  hue.  Swelling 
results  from  exudation  and  varies  greatly  in  difterent  parts  of  the  body. 
Disturbance  of  function  results  directly  from  the  pain  and  swelling  of 
the  inflamed  parts. 

The  constitutional  symptoms  naturally  vary  greatly  with  the  sever- 
ity and  location  of  the  lesion.  In  mild  cases  slight  or  none  are  present, 
while  in  severe  inflammations  chills,  fever  and  even  prostration  are 
often  seen. 

Treatment. — Treatment  resolves  itself  into  local  and  constitutional. 
Local  treatment  has  tln'ee  main  things  in  view,  namely:  (1)  removal  of 
the  cause  of  the  inflammation;  (2)  rest  of  the  affected  part;  (3)  reduc- 
tion of  the  swelling  and  hyperemia,  with  relief  of  pain.  Causative 
bacteria  are  removed  by  thorough  drainage  of  suppurating  wounds, 
with  deep  pockets,  and  especially  is  drainage  important  where  the  pus 
is  under  great  pressure.     Rest  of  the  affected  part  is  essential  as  it 


128  INFLAMMATION  AND  HEALING  OF  WOUNDS 

greatly  diminishes  the  amount  of  blood  to  the  inflamed  area,  lessens 
the  pain  and  decreases  both  the  spread  of  the  inflammation  and  the 
danger  of  general  sepsis.  In  inflammation  of  the  extremities,  elevation 
of  the  arm  or  leg  after  the  proper  application  of  a  hot  boric-acid-alcohol 
dressing,  extending  well  beyond  the  area  involved  proximal  as  far  as 
the  body,  not  only  lessens  the  swelling  and  decreases  the  pain,  but 
tends  to  hasten  convalescence  and  to  prevent  widespread  dissemination 
of  the  invading  bacteria  in  the  blood  stream. 

Hot  and  cold  applications  as  the  patient  desires  may  be  valuable 
in  relieving  tumefaction  and  pain  in  earlier  stages  of  inflammation. 
Bier's  'passive  hyperemia"  treatment  is  based  on  the  belief  that  the 
increased  number  of  blood  corpuscles  and  the  excess  of  blood  serum 
exert  favorable  action  on  inflammatory  processes.  He  advocates 
obtaining  this  increased  hyperemia  either  by  constriction  above  the 
zone  of  inflammation  or  by  a  suction  apparatus.  Constitutional  treat- 
ment demands  the  use  of  tonics  together  with  proper  dietetic  manage- 
ment and  plenty  of  sunshine  and  fresh  air  in  the  chronic  inflammatory 
processes,  which  may  pro^•e  to  be  of  tuberculous,  luetic  or  rheumatic 
origin.  Finally,  I  wish  to  emphasize  the  splendid  results  obtained  in  the 
treatment  of  inflammations  and  infections  bj^  the  application  of  the 
simple  therapeutic  light  as  employed  at  the  Augustana  Hospital.  The 
rapidity  with  which  inflammatory  processes  subside  and  the  great 
comfort  and  diminished  pain  afforded  the  patient  convinces  one  of  the 
practical  value  of  this  simple  measure. 

HEALING  OF  WOUNDS. 

The  repair  or  healing  of  wounds  is  a  normal  physiological  process  as 
contrasted  with  inflammation,  which  is  distinctly  a  pathological 
process.  Repair  goes  on  hand-in-hand  with  inflammation.  Within 
twenty-four  hours  the  edges  of  a  wound  may  be  glued  together  by 
fibrin  and  mitotic  figures  can  be  demonstrated  in  the  connective 
tissues.  In  the  repair  of  tissues  the  parenchyma  cells  play  but  little 
part,  the  connective  tissues  play  the  chief  role.  Indeed,  it  ma}^  be 
stated  as  a  general  rule,  that  the  more  highly  specialized  the  tissue  the 
less  its  power  of  regeneration. 

Before  repair  begins,  large  amounts  of  inflammatory  debris  must 
be  removed.  The  polynuclears  and  large  mononuclear  cells  present 
in  the  inflammatory  exudate  act  as  scavengers,  engulfing  bacteria, 
digesting  dead  tissues  and  picking  up  fragments  to  eventually  make 
their  way  to  the  dilated  hnnphatics.  The  l}inph  glands  act  as  mechani- 
cal and  chemical  filters  and  thus  protect  the  blood  stream  from  noxious 
material.  Gradually  the  field  of  inflammation  is  cleared  up  and  the 
way  paved  for  healing. 

The  phenomena  of  repair  may  best  be  studied  in  the  healing  of  a 
surgical  incision.  When  an  incised  wound  heals  without  suppuration 
the  process  is  called  "primary  union"  or  healing  by  first  intention. 
Within  twenty-four  hours  the  wound  edges  are  glued  together  by 


HEALING  OF  WOUNDS  129 

fibrin.  The  leukocytes  have  largely  removed  the  inflammatory 
debris.  The  fixed  connective-tissue  cells  and  the  endothelial  cells  pro- 
liferate to  form  the  fibroblasts  or  young  connective-tissue  cells.  From 
the  walls  of  the  capillaries  little  protoplasmic  offshoots  or  buds  develop 
which  unite  with  similar  capillary  buds  of  other  vessels  to  become 
canalized  as  new  capillaries  and  thus  the  organization  or  vasculari- 
zation of  the  newly  formed  granulation  tissue  is  effected  and  the  wound 
is  well  on  the  way  to  healing  by  primary  union.  Granulation  tissue, 
at  first  red,  later  contracts  dovin  thereby  compressing  the  newly 
formed  capillaries  and  becoming  hard  and  pale  white.  At  a  later  date 
the  epithelium  grows  from  the  skin  margins  to  bridge  the  gap. 

Healing  by  "second  intention,"  or  gramdation  is  always  associated 
ynth  more  or  less  suppuration  and  results  when  the  wound  becomes 
infected  and  there  is  a  loss  of  considerable  tissue  through  sloughing. 
The  edges  of  the  wound  may  become  separated  and  the  wound  defect 
fills  up  from  the  bottom  by  the  formation  of  friable  capillary  tufts 
surrounded  by  newly  formed  fibroblasts.  As  new  fibroblasts  develop 
and  become  vascularized  the  cavity  is  finally  completely  obliterated. 
The  epithelium  gradually  grows  inward  by  proliferation  of  the  marginal 
cells  and  healing  by  granulation  is  complete. 


SURGICAL  EEVEE  AND  INFECTIONS. 


By  JOHN  W.  NUZUM,  B.S,,  M.D. 

General  Nature  of  Fever. — Fever  is  a  reaction  on  the  part  of  the  body, 
under  control  of  the  nervous  system,  and  specially  of  the  vasomotor 
mechanism,  which  has  to  do  with  the  heat  regulation.  Any  elevation 
above  the  normal  temperature  of  the  body  constitutes  fever.  The 
process  is  usually  associated  with  or  accompanies  inflammations  or 
infections  of  the  body.  It  should  be  emphasized  that  fever  is  not  a 
harmful  process  to  be  dispelled  by  antip^Tctics  and  the  use  of  cold 
packs,  as  was  formally  believed,  but  rather  represents  a  reaction  on  the 
part  of  the  body,  whereby  certain  substances  are  formed  in  the  blood 
stream  to  neutralize  the  toxins  and  destroy  the  invading  bacteria. 

Fever  is  associated  with  a  definite  derangement  of  the  heat-regulating 
mechanism.  Oxidation  processes  are  increased  and  both  carbohydrates 
and  fats  are  burned  up  to  supply  heat  energy. 

Fever  as  an  Immunity  Reaction. — There  is  real  experimental  and  clini- 
cal evidence  to  prove  that  fever  is  a  defensive  and  protective  process 
rather  than  a  harmful  one.  It  has  been  shown  that  animals  placed  in 
thermostats  at  elevated  temperatures  developed  specific  antibodies  in 
the  blood  stream,  w^hich  enabled  them  to  neutralize  and  destroy  lethal 
doses  of  bacteria.  Moreover,  a  definite  and  marked  increase  in  the 
agglutinins  and  bacteriolytic  substances  occurs  in  the  blood  of  these 
animals  as  compared  with  the  controls. 

The  clinical  evidence  of  the  protective  value  of  febrile  reactions  is 
well  demonstrated  in  the  striking  results  that  follow  intravenous 
injections  of  foreign  proteins  in  acute  painful  arthritis.  Patients  with 
painful,  swollen  joints  often  experience  a  most  rapid  disappearance  of 
pain  after  a  severe  febrile  reaction  which  follows  the  injection.  Careful 
investigations  of  this  phenomenon  have  shown  that  in  general  the  best 
results  occur  in  those  cases  which  suffer  a  severe  reaction,  viz.,  a  severe 
chill  followed  by  a  temperature  of  102°  to  even  105°  C. 

The  foreign  protein  calls  forth  a  leukocytosis  and  both  specific  and 
non-specific  antibodies  are  increased  in  the  blood  stream. 

On  the  other  hand  it  is  well-known  that  in  certain  disease  processes, 
such  as  pneumonia  in  alcoholics,  or  the  aged,  general  peritonitis,  etc., 
when  the  patient  runs  a  subnormal  temperature  with  a  low  white  count 
or  perhaps  a  leukopenia,  the  outcome  is  frequently  associated  with  a 
grave  prognosis.  Here  again  it  would  seem  that  fever  may  be  an  index 
of  the  body  resistance  to  infection. 

(131) 


132  SURGICAL  FEVER  AND  INFECTIONS 

ASEPTIC  TRAUMATIC  FEVER. 

Aside  from  elevation  of  temperature  associated  with  infections  the 
surgeon  meets  with  a  type  of  fever  known  as  traumatic  fever  or 
" postoperation  rise."  This  fever  occurs  after  aseptic  operations, 
sprains,  fractures,  wounds  and  contusions,  and  is  characterized  by  the 
absence  of  microorganisms  at  the  site  of  injury  or  in  the  operative 
wound.  This  mild  type  of  fever  commonly  appears  the  evening  of  the 
day  of  operation  and  persists  for  twenty-four  to  forty-eight  hours, 
reaching  a  maximum  of  100°  to  102°.  It  is  not  accompanied  by  a  chill, 
and  aside  from  the  slight  elevation  of  temperature  the  patient  feels 
well.  The  blood  often  shows  a  moderate  leukocytosis.  The  wound 
looks  entirely  normal  and  is  not  painful,  red  or  swollen.  The  fever  is 
presumably  due  to  the  absorption  of  the  products  of  cellular  disin- 
tegration, fibrin  ferment,  serous  exudate  and  extravasated  tissue 
juices.  If  of  mild  duration,  it  has  no  prognostic  significance  and 
requires  no  special  treatment.  Howe^•er,  a  fever  appearing  three  or  four 
days  after  operation  and  persisting  practically  always  means  infection 
and  demands  immediate  inspection  of  the  operative  incision,  A  painful 
wound  with  red  swollen  margins  is  usually  grossly  infected.  The  ten- 
sion sutures  must  be  loosened,  and  where  pus  is  present  in  the  sub- 
cutaneous tissues  the  wound  should  be  laid  wide  open  and  hot  dressings 
applied  to  prevent  burrowing  or  deep  dissemination  of  the  infection. 
At  a  later  time  secondarv  suture  mav  be  necessarv. 


MALIGNANT  SEPTIC  INFECTIONS. 

Introduction. — A  consideration  of  surgical  infections  necessarily  calls 
for  a  discussion  of  septicemia  and  pyemia.  Infection  may  be  defined 
as  the  condition  produced  by  the  entrance  and  multiplication  of 
pathogenic  microorganisms  within  the  body.  In  local  infection  the 
growth  of  the  bacteria  is  largely  restricted  to  the  portal  of  entry  and 
the  associated  tissue  changes  result  from  the  toxic  substance  elabo- 
rated by  the  bacteria.  When  these  toxic  substances  pass  into  the 
general  circulation,  giving  rise  to  mild  or  grave  constitutional  s;sinp- 
toms,  the  condition  is  known  as  toxemia.  Diphtheria  furnishes  an 
excellent  example  of  a  toxemia,  since  the  growth  of  the  bacilli  is 
largely  restrained  to  the  exudate  over  the  tonsils  and  soft  palate  while 
the  complicating  paralysis  of  the  muscles  of  the  soft  palate  is  due  to 
the  effect  of  the  toxins  on  the  nerve  supply  to  these  tissues.  Sapremia 
is  an  obsolete  and  vague  term  applied  to  those  conditions  in  which  the 
sjTnptoms  are  due  to  the  absorption  of  poisonous  products  of  decom- 
position without  the  presence  of  microorganisms  in  the  general  blood 
stream.  Sapremia  is  well  illustrated  by  the  symptoms  arising  during 
the  puerperium  from  portions  of  placental  tissue  retained  within  the 
uterus  and  undergoing  decomposition. 

When  during  the  course  of  infection  pathogenic  microorganisms  gain 
entrance  through  the  hmphatics  into  the  blood  stream  and  multiply 


MALIGNANT  SEPTIC  INFECTIONS  133 

in  the  blood  and  tissues  of  the  body  the  process  is  known  as  septicemia. 
Formerly,  septicemia  was  considered  as  a  surgical  affection  limited 
largely  to  the  pyogenic  bacteria,  namely,  the  Streptococcus  and  Staphy- 
lococcus pyogenes  aureus.  More  recent  investigations  have  shown 
conclusively  that  many  of  the  acute  infectious  diseases,  such  as  pneu- 
monia, typhoid  fever,  epidemic  cerebrospinal  meningitis,  rheumatic 
fever,  etc.,  are  all  accompanied  by  an  early  general  invasion  of  the 
blood  stream  by  the  causative  bacteria,  with  later  specific  localization 
in  the  various  tissues.  Blood  cultures  taken  early  during  the  febrile 
period  of  the  disease  or  at  the  time  of  a  chill  will  often  yield  pure  cul- 
tures of  the  causative  microorganism,  although  the  percentage  of  posi- 
tive cultures  is  largely  dependent  on  the  cultural  media  employed 
and  the  technic  and  experience  of  the  bacteriologist.  To  this  general 
blood-stream  invasion  the  broader  and  more  *  comprehensive  term 
bacteremia  has  been  applied. 

If  during  the  course  of  a  septicemia  or  bacteremia,  the  invading 
microorganisms  give  rise  to  the  formation  of  multiple  metastatic 
suppurative  foci  or  abscesses  in  various  organs  of  the  body  the  con- 
dition is  kno\\'n  as  pyemia.  It  will  thus  be  seen  that  these  different 
infectious  processes  are  closely  linked  together  and  may  be  said  to 
represent  various  degrees  of  severity  of  infection,  depending  largely  on 
the  general  defensive  powers  of  the  human  body.  Pyemia  presupposes 
the  existence  of  a  septicemia  or  bacteremia  and  represents  merely 
the  end-picture  of  the  disease. 

Etiology. — The  etiology  of  septicemia  and  pyemia  will  be  considered 
together.  Our  information  is  entirely  due  to  the  careful,  painstaking, 
bacteriological  examinations  of  the  blood  during  life,  together  with 
routine  cultural  examinations  of  the  body  tissues  and  fluids  at  necropsy. 
It  is  obvious  that  septicemia  can  result  only  from  infection  somewhere 
within  the  body,  but  the  portal  of  entry  of  the  bacteria  is  frequently" 
difficult  to  determine.  It  may  result  from  an  attack  of  tonsillitis,  from 
infected  teeth,  otitis  media,  sinusitis,  prostatitis,  chronic  appendicitis, 
gall-bladder  disease,  pelvic  infections  or  gastric  ulcer.  The  septicemia 
often  results  from  a  trivial  scratch  which  has  been  forgotten  or  from 
a  superficial  pin-prick  of  the  finger.  Finally  a  most  careful  search  may 
fail  to  reveal  the  portal  of  entry  of  the  infection  and  to  this  class  the 
name  cryptogenic  septicemia  is  given.  It  should  not  be  forgotten 
that  the  bacteremia  following  pneumonia  is  frequently  due  to  the 
causative  microorganisms,  the  pneumococcus,  while  in  scarlet  fever  a 
septicemia  often  is  due  to  the  common  secondary  invader,  the  strep- 
tococcus. 

The  organisms  isolated  from  septicemias  in  relative  order  of  impor- 
tance and  frequency  are  as  follows:  the  Streptococcus,  Staphylococcus 
pyogenes  aureus,  Pneumococcus,  Bacillus  tj-phosus.  Colon  bacillus, 
Bacillus  pyocyaneus.  Bacillus  mucosus  capsulatus.  Meningococcus  and 
some  few  others. 

Terminal  Infections. — Patients  suffering  from  chronic  diseases  of  the 
heart,  kidneys,  liver  and  lungs  frequently  succumb  as  a  result  of 


134  SURGICAL  FEVER  AND  INFECTIONS 

secondary  or  terminal  infections.  Osier  is  authority  for  the  statement 
that  "the  majority  of  cases  of  advanced  arteriosclerosis  and  of  Bright's 
disease  succumb  to  these  intercurrent  infections." 

Flexner  in  a  large  series  of  793  autopsies  found  255  cases  of  chronic 
heart  and  kidney  disease,  in  213  either  a  local  or  general  infection  was 
present  and  in  52  there  was  a  general  infection  of  the  body.  He  found 
the  following  organisms  in  order  of  f reciuency :  Streptococcus  pyogenes, 
jMicrococcus  lanceolatus,  Staphylococcus  pyogenes  aureus,  Bacillus 
welchii,  Bacillus  coli,  ^Micrococcus  gonorrhoeae.  Bacillus  anthracis  and 
Bacillus  proteus. 

Technic  and  Value  of  Blood  Cultures.- — It  is  obvious  that  bacterio- 
logical examinations  of  the  blood  during  life  yields  information  of 
great  scientific,  diagnostic,  therapeutic  and  prognostic  value.  ]More- 
over,  the  rational  emplo\'ment  of  both  sera  and  vaccines  absolutely 
demands  an  accurate  knowledge  of  the  pathogenic  microorganisms 
responsible  for  the  disease.  The  persistence  of  large  numbers  of  colo- 
nies of  pneumococci  in  the  blood  stream  during  pneumonia  gives  a 
distinctly  bad  prognosis.  The  differential  diagnosis  between  miliary 
tuberculosis  and  typhoid  fever  is  immediately  established  by  positive 
cultures  of  Bacillus  t\'phosus  when  the  clinical  symptoms  and  physical 
findings  are  indefinite.  It  must  be  remembered  that  in  septicopyemia, 
osteomyelitis  or  suppuration,  bacteria  may  only  be  present  in  the  blood 
at  intervals,  and  especially  is  this  liable  to  be  true  during  the  chill. 

The  method  of  obtaining  cultures  from  the  blood  may  be  briefly 
outlined  as  follows:  The  skin  is  carefully  cFeansed  with  alcohol  or 
ether  and  may  be  painted  with  iodin.  A  constrictor  is  placed  on  the 
arm  and  the  blood  is  withdrawn  by  venipuncture  into  a  sterile  glass 
sj-ringe  attached  to  a  sharp  needle.  The  median  basilic  or  cephalic 
vein  at  the  elbow  is  conveniently  selected.  Before  clotting  the  fluid 
blood  is  inoculated  in  small  amounts,  viz.,  5  c.c.  blood  into  50  or  100 
c.c.  flasks  of  dextrose  ascitic  broth.  Great  care  must  be  exercised  to 
avoid  aerial  contamination.  By  using  small  amounts  of  blood  the 
natural  bactericidal  properties  of  the  blood  may  be  largely  overcome. 
Anaerobic  cultures  and  inoculations  of  blood-agar  plates  should  also 
be  made.  Staphylococci  are  frequently  contaminations  from  the  skin 
puncture.  The  inoculated  cultural  media  is  placed  in  the  thermostat 
at  35°  C,  and  allowed  to  incubate  for  twelve  days.  Daily  examinations 
are  made  for  evidence  of  bacterial  growth,  viz.,  turbidity  and  the 
organism  is  identified  by  morphological  study  of  stained  smears,  cul- 
tural reactions  and  serological  determinations.  Certain  of  the  less 
common  pathogenic  bacteria  require  special  media  for  isolation. 

Morbid  Anatomy. — The  bodies  of  patients  dead  from  septicemia 
present  little  or  no  postmortem  rigidity.  Decomposition  begins  very 
early  after  death.  The  blood  shows  little  tendency  to  clot  and  post- 
mortem hemolytic  staining  of  the  lining  of  the  aorta  and  of  the  serous 
surfaces  of  the  pleura  and  endocardium  are  often  marked.  Dissemi- 
nated petechial  hemorrhages  are  present  beneath  the  skin,  and  especially 
in  the  pleura,  pericardium  and  epicardium.    Occasionally  these  minute 


MALIGNANT  SEPTIC  INFECTIONS  135 

hemorrhages  predominate  throughout  the  body  in  so-called  cases  of 
hemorrhagic  septicemia.  The  spleen  is  generally  enlarged.  The 
capsule  may  be  soft  and  wrinkled  and  the  splenic  pulp  is  frequently 
soft  and  mushy.  The  heart,  liver  and  kidneys  present  the  common 
picture  of  cloudy  swelling  and  fatty  changes.  An  old  otitis  media, 
prostatic  abscess  or  diseased  appendix  at  autopsy  may  represent  the 
hidden  portal  of  entry  of  the  infection. 

Pathology  of  Pyemia. — In  discussing  the  pathology  of  pyemia  we 
must  assume  the  presence  of  pyogenic  organisms  in  the  blood  stream, 
but  the  essential  characteristic  is  the  development  of  multiple  sup- 
purative foci  in  various  organs  and  tissues  of  the  body.  In  the  majority 
of  local  suppurative  processes  leading  to  pyemia  the  walls  of  the  veins 
adjacent  "to  the  area  undergo  an  inflammatory  process  leading  to  the 
production  of  a  thrombophlebitis.  Small  portions  of  these  infected 
thrombi  are  swept  into  the  blood  stream  and  lodge  usually  in  the  lungs 
in  the  small  capillaries  or  terminal  vessels.  Since  these  are  infected 
emboli  they  produce  widely  disseminated  minute  metastatic  abscesses, 
with  a  central  zone  of  clumped  microorganisms  surrounded  by  a  small 
area  of  necrosis  and  beyond  this  an  area  of  leukocytic  infiltration 
encapsulated  by  newly  formed  connective  tissue.  It  has  been 
demonstrated  experimentally  that  anything  which  causes  clumping 
or  agglutination  of  the  bacteria  favors  the  development  of  abscess 
formation  in  the  tissues.  Moreover,  bacteria  in  the  blood  stream  show 
a  special  tendency  to  localize  at  the  site  of  injured  tissues.  Indeed, 
it  has  been  found  possible  to  produce  osteomyelitis  in  animals  by 
fracturing  a  bone  and  then  introducing  microorganisms  intravenously 
as  they  tend  to  be  arrested  at  the  site  of  the  fracture  and  set  up  an 
acute  suppurative  process.  In  a  similar  manner  appendicitis  can  be 
produced  by  crushing  or  ligaturing  the  appendix  prior  to  intravenous 
inoculation.  Endocarditis  in  animals  is  readily  induced  by  intravenous 
injection  of  pj^ogenic  bacteria,  provided  that  the  valve  is  the  site  of  a 
previous  mechanical  injury.  There  can  be  no  doubt  that  this  factor 
of  lowered  resistance  or  tissue  injury  (locus  minoris  resistentias)  is  a 
very  important  element  in  the  production  of  pyemia  as  well  as  in  the 
causation  of  other  acute  disease  processes. 

Thrombophlebitis  in  the  neighborhood  of  pulmonary  abscesses  may 
give  rise  to  showers  of  minute  metastatic  abscesses  in  the  kidneys, 
spleen,  myocardium,  brain  or  muscles. 

An  unusual  form  of  pyemia  is  that  resulting  from  infections  of  the 
gall-bladder,  stomach,  bowel  or  most  frequently  in  the  appendix  lead- 
ing to  the  production  of  a  septic  thrombosis  of  the  portal  vein,  with 
multiple  abscesses  of  the  liver,  a  condition  always  fatal  and  known  as 
suppurative  pylephlebitis. 

Symptomatology.— Septicemia  frequently  complicates  the  puerperium, 
due  to  errors  in  technic  at  the  time  of  labor,  i.  e.,  the  so-called  puerperal 
sepsis.  A  common  and  severe  type  of  septicemia  follows  infections  in 
the  postmortem  room.  A  slight  abrasion  of  the  finger  or  hand  within 
a  few  hours  may  present  the  red  streaks  of  lymphangitis  running  up 


136  SURGICAL  FEVER  AND  INFECTIONS 

the  patient's  arm.  The  epitrochlear  and  axillary  glands  become 
swollen  and  painful.  There  are  frequent  chilly  sensations  or  actual 
rigors  followed  by  fever,  usually  moderate,  but  often  high.  The  patient 
is  prostrated  and  takes  to  bed.  The  fever  often  shows  morning  remis- 
sions and  evening  exacerbations.  As  the  case  progresses  the  tem- 
perature may  fluctuate  greatly.  The  pulse  is  rapid  and  weak.  The 
tongue  is  dry  and  furred.  The  urine  is  scanty  in  amount  and  of  high 
color.  Sweating  may  be  profuse.  Vomiting  and  diarrhea  are  often 
prominent  symptoms.  Prostration  dominates  the  general  picture. 
The  spleen  may  be  palpable.  There  is  a  progressive  and  se\'ere  secon- 
dary anemia.  Leukocytosis  is  usually  marked  except  in  those  cases 
which  succumb  before  the  body  has  an  opportunity  to  react.  Repeated 
blood  cultures  taken  during  a  chill  will  often  yield  pure  cultures  of  the 
microorganisms  responsible  for  the  condition.  A  negative  culture  has 
no  value  while  a  positive  result  often  gives  information  of  prognostic 
and  therapeutic  value.  Toward  the  end  the  patient  may  present  the 
so-called  facies  Hippocratica,  i.  c,  pinched  nose,  hollow  temples, 
sunken  eyes,  etc.  Low  muttering  delirium  gradually  is  replaced  by 
stupor  and  death.  Li  the  more  protracted  cases  bronchopneumonia, 
lung  abscesses,  endocarditis,  meningitis,  peritonitis,  arthritis  or  even 
osteomyelitis  may  appear  as  complicating  sequelse. 

The  symptoms  of  pyemia  are  quite  similar  to  septicemia.  The 
disease  is  ushered  in  by  a  severe  chill  or  a  series  of  chills.  The  tem- 
perature rises  rapidly  and  fluctuates  widely.  With  each  successive 
shower  of  septic  emboli  there  occurs  a  severe  chill  followed  by  drench- 
ing sweats.  The  temperature  is  subject  to  the  greatest  variations  and 
may  even  drop  to  normal,  only  to  shoot  up  again  when  new  foci  of 
suppuration  develop  in  distant  organs.  The  general  symptoms  of 
great  prostration  and  weakness,  vomiting,  petechial  hemorrhages  in 
the  skin,  etc.,  are  similar  to  those  of  septicemia.  Acute  pyemia  may 
end  fatally  within  a  week  while  chronic  cases  may  drag  along  for 
several  months.    The  complications  have  been  considered  above. 

Diagnosis. — A  patient  presenting  in  general  the  symptoms  tabulated 
in  the  above  paragraphs  in  association  with  a  suppurating  wound,  an 
old  osteomyelitis,  chronic  otitis  media  or  a  compound  infected  fracture 
must  at  once  suggest  the  possibility  of  a  septicemia  or  pyemia.  When 
the  s^^llptoms  develop  rapidly  after  childbirth  or  subsequent  to  an 
autopsy  infection  the  diagnosis  is  easy.  Positive  blood  cultures  render 
the  diagnosis  absolutely  certain. 

It  is  extremely  important  to  determine  the  portal  of  entry,  as  many 
chronic  septicemias  due  to  absorption  of  the  microorganisms  from 
infected  tonsils,  carious  teeth,  sinus  disease,  chronic  appendicitis  or 
gall-bladder  infection  clear  up  quickly  after  appropriate  surgical 
treatment.  Li  those  forms  of  septicemia  and  pyemia  due  to  hidden 
foci  of  infection  such  as  prostatic  abscesses,  posterior  urethritis  or 
intestinal  tract  disease,  the  diagnosis  is  often  difficult  and  is  frequently 
misinterpreted  as  malaria,  typhoid  fever  or  miliary  tuberculosis. 
Pyemia  is  to  be  suggested  from  the  character  of  the  fever  and  the  local- 


MALIGNANT  SEPTIC  INFECTIONS  137 

izing  symptoms  of  complicating  abscesses  when  present  in  the  lungs, 
kidneys,  etc. 

Prognosis. — The  prognosis  naturally  varies  with  the  age  of  the  patient, 
duration  of  the  disease,  type  of  infecting  microorganisms  and  the  defen- 
sive power  of  the  body.  In  general  it  may  be  stated  that  streptococcal 
septicemia  offers  the  worst  prognosis.  In  surgical  septicemia,  puer- 
peral sepsis,  etc.,  complicated  by  meningitis,  peritonitis  or  endo- 
carditis, the  death-rate  is  very  high.  Suppurative  pylephlebitis  is 
always  fatal.  In  the  chronic  types  of  pyemia  with  mild  joint  involve- 
ment recovery  often  follows. 

Treatment. — The  treatment  naturally  falls  into  three  general 
divisions,  viz.,  local,  general  and  specific. 

Local  Treatment. — Local  treatment  demands  the  eradication  of  all 
foci  of  suppuration.  Abscesses  must  be  drained,  carious  teeth  extracted, 
middle-ear  disease  treated — in  fact  a  most  thorough  search  should 
be  instituted  for  hidden  foci  of  infection  which  may  be  feeding  bacteria 
into  the  general  blood  stream.  The  tonsils,  prostate  and  genito- 
urinary tract  must  not  be  overlooked. 

General  Treatment. — Absolute  rest  in  bed  is  imperative.  Fresh  air 
can  only  do  good.  A  liquid  diet  of  high  caloric  value  and  given  at 
frequent  intervals  is  essential.  Rectal  feedings  may  be  necessary. 
Copious  consumption  of  large  quantities  of  water  is  always  beneficial, 
as  it  promotes  elimination  through  the  kidneys,  bowels  and  skin. 
Hydrotherapy  may  be  employed.  Saline  hypodermoclysis  is  often  of 
value.  Digitalis  should  be  administered  for  a  weak  heart.  Repeated 
blood  transfusions  are  of  benefit  in  those  chronic  cases  with  marked 
secondary  anemia  and  low  bactericidal  properties  in  their  blood. 

Specific  Treatment.- — This  method  of  therapy  demands  a  careful 
bacteriological  study  of  the  patient's  blood.  If  the  septicemia  is  due 
to  the  streptococcus,  large  doses  of  antistreptococcal  serum  (polyv- 
alent) may  be  given  intravenously,  and  as  early  in  the  course  of 
the  disease  as  possible.  Investigations  have  shown  that  the  strepto- 
cocci fall  into  several  distinct  classes.  Each  type  possesses  different 
cultural  and  serological  characteristics  and  the  questionable  results  of 
streptococcal  serum  therapy  may  be  due  to  previous  inadequate  dosage 
or  actual  impotency  of  the  serum.  The  serum  when  properly  given  is 
harmless,  and  in  addition  to  its  high  opsonin  content  it  stimulates  the 
production  of  both  specific  and  non-specific  antibodies  in  the  blood 
stream  of  the  patient. 

In  general  it  may  be  said  that  our  knowledge  of  the  streptococci  as 
a  group  is. as  yet  very  incomplete  and  the  disappointing  results  of 
streptococcal  serum  therapy  in  the  past  may  be  directly  attributed  to 
this  fact.  Recent  epidemics  of  a  peculiar,  highly  fatal  type  of  broncho- 
pneumonia developing  among  soldiers  convalescing  from  measles  has 
been  definitely  shown  to  be  due  to  the  hemolytic  streptococci.  The 
antigenic  properties  of  these  hemolytic  streptococci  and  the  thera- 
peutic value  of  specific  serum  therapy  are  problems  for  future 
bacteriological  study  to  solve. 


POSTOPERATIVE  TREATMENT. 


By  JOHN  H.  GIBBON,  M.D. 

In  no  department  of  surgery  will  be  found  the  exhibition  of  so  great 
a  display  of  individuality  as  in  the  after-treatment.  Many  surgeons 
are  inclined  to  attribute  their  good  results  to  their  peculiar  plan  of 
postoperative  care  and  yet,  others,  carrying  out  a  postoperative  treat- 
ment which  is  the  exact  opposite,  claim  equally  good  results.  In 
recent  years,  however,  there  has  been  more  unanimity  of  opinion,  less 
stoutness  in  adhering  to  fixed  rules,  and  more  consideration  shown  to 
the  individual  patient.  The  change  which  has  come  about  has  been 
distinctly  toward  simplicity  and  a  postoperative  treatment  directed 
especially  toward  the  patient's  comfort.  These  changes  speak  for 
reason  and  common  sense.  It  is  foolish  to  attempt  to  lay  down  for 
instance  an  iron-clad  rule  that  every  patient  must  have  a  bowel  move- 
ment on  a  certain  day  following  operation  and  equally  absurd  to  say 
that  every  patient,  after  an  operation,  must  have  water  withheld  from 
the  stomach  for  a  definite  number  of  hours.  Common  sense  must 
guide  us  to  a  large  extent,  for  in  one  case  it  may  be  imperative  to  have 
the  bowels  open  the  day  after  operation  and  in  another  no  necessity 
for  a  movement  for  several  days;  one  patient  may  be  able  to  take 
water  within  a  few  hours  after  operation  without  nausea  or  ill  effect 
where  another  may  have  his  postoperative  discomfort  and  nausea 
greatly  increased.  It  should  be  understood  therefore  that  what  follows 
must  not  be  taken  as  an  inflexible  guide  never  to  be  departed  from 
unless  it  is  so  stated. 

Paradoxical  as  it  may  sound,  postoperative  treatment  really  begins 
before  the  operation  in  the  preparation  of  the  patient  for  the  operation 
and  extends  throughout  the  operation  itself  because  prevention  is  the 
most  important  part  of  treatment  and  much  can  be  done  before  and 
during  the  operation  to  accomplish  it.  No  discussion  of  postoperative 
treatment  would  be  complete  without  mention  of  some  of  the  factors 
which  produce  postoperative  discomfort  and  complications  and  these 
should  receive  the  first  consideration. 

Correct  Diagnosis. — It  may  not  be  amiss  in  considering  the  post- 
operative comfort  and  safety  of  the  patients  to  say  that  a  correct 
diagnosis|before  the^operation  adds  greatly  to  both.  The  failure  to 
study  carefully  our  patients,  or  to  call  to  our  aid  the  various  laboratory 
methods  of  diagnosis,  the  tendency  to  look  upon  conditions  as  emer- 
gencies which  are  not  emergencies  at  all  and  to  do  exploratory  oper- 
ations upon  patients  where  an  approximate  diagnosis  can,  with  a  little 

(139) 


140  POSTOPERATIVE  TREATMENT 

care  and  effort,  be  made  beforehand,  result  too  often  in  a  multiplication 
of  incisions,  a  repetition  of  the  operation  and  occasionally  in  the 
unnecessary  death  of  the  patient.  Haste  to  operate  in  a  case  of  appendi- 
citis complicated  by  some  acute  infection  of  the  respiratory  mucous 
membrane,  "just  an  ordinary  cold,"  is  sure  to  result  in  a  serious  lung 
infection  after  the  operation  and  serves  to  illustrate  one  of  the  points 
I  would  make.  Hasty  operations  done  for  supposed  acute  abdominal 
crises,  when  the  real  condition  is  a  pneumonia  or  a  pleurisy,  is  another 
illustration.  And  still  others  are  the  hurried  operations  which  have 
been  done  in  cases  of  typhoid  fever  under  the  impression  that  the 
patients  were  suffering  from  aj^pendicitis  and  where  a  simple  leukocyte- 
count  would  have  resulted  in  the  avoidance  of  these  catastrophes. 

It  is  these  mistakes  which  we  have  made  in  the  past  that  cause  me  to 
suggest  that  a  correct  diagnosis  before  operation  has  a  remarkable 
bearing  on  the  result  and  that  hasty  operations  and  those  not  preceded 
by  a  careful  study  of  the  patient  and  the  employment  of  all  those 
measures  which  aid  diagnosis  and  tend  to  indicate  the  risk  of  operation 
and  the  patient's  ability  to  withstand  them,  not  only  bring  discomfort, 
danger,  and  often  disaster  to  the  patient,  but  are  a  distinct  discredit 
to  the  surgeon  and  to  surgery. 

Choice  of  Anesthetic. — Probably  in  certain  cases  nothing  contributes 
more  to  the  patient's  postoperative  safety  than  a  proper  choice  of 
anesthetic.  Every  experienced  surgeon  has  a  very  marked  preference 
for  a  certain  anesthetic  and  is  prepared  to  defend  it  on  all  occasions, 
and  it  is  not  my  idea  to  attempt  to  change  the  opinion  of  any  one  in 
regard  to  his  favorite  anesthetic  agent,  but  rather  to  urge  that  no  one 
agent  is  always  the  best.  There  is  no  "safest  anesthetic"  for  all  cases. 
Ether,  generally  speaking,  is  probably  the  least  dangerous  of  anes- 
thetics, but  its  irritating  properties  contra-indicate  its  use  in  the  presence 
of  acute  infections  of  the  respiratory  tract,  where  nitrous  oxide,  chloride 
of  ethyl,  regional  anesthesia  or  infiltration  anesthesia  can  be  used  with 
comparative  safety.  In  nephritis  too,  ether,  instead  of  being  a  safe 
anesthetic,  becomes  a  dangerous  one.  In  disease  of  the  heart  valves 
and  muscle,  nitrous  oxid,  chloride  of  ethyl  and  chloroform  are  far  more 
dangerous  than  ether.  The  use  of  some  one  of  the  various  forms  of 
regional  or  local  anesthesia  often  places  a  particular  operation  in  the 
category  of  safety,  whereas  a  general  anesthetic  might  make  it  unjusti- 
fiable. The  use  of  intratracheal  anesthesia  and  of  spinal  anesthesia  in 
certain  operations  is  plainly  indicated  and  much  safer  than  the  ordinary 
means  of  bringing  about  the  anesthetic  state.  What  we  need  is  a 
broader  experience  in  the  use  of  all  anesthetics  and  the  ability  to  exercise 
a  wise  choice  in  the  selection  of  the  particular  anesthetic  or  method  of 
administration  in  the  individual  case.  There  can  be  no  doubt  that 
such  broader  experience  and  choice  of  anesthetic  will  influence  favorably 
the  early  recovery  and  convalescence  of  our  patients.  I  cannot  leave 
this  subject  without  stating  as  a  firm  conviction  that  the  adminis- 
tration of  morphin  and  atropin  by  h^qjodermic  one-half  hour  before 
the  operation,  not  only  results  in  a  better  and  more  complete  anes- 


FIELD  OF  OPERATION  141 

thesia,  but  that  it  also  helps  to  reduce  the  amount  of  the  anesthetic 
to  be  used  during  the  operation,  tends  to  prevent  shock  and  adds 
enormously  to  the  patient's  comfort  and  safety  during  the  few  hours 
immediately  following  the  operation. 

Alimentary  Tract. — The  former  method  of  administering  a  purgative 
the  night  before  operation  has  been  given  up  by  most  surgeons  and 
wisely  because,  in  abdominal  operations  especially,  the  patients  suffer 
in  the  postoperative  period  from  gas  and  harmful  peristalsis;  more- 
over, the  sleep  and  rest  which  they  should  have  on  the  night  preceding 
operation  is  disturbed.  It  is  far  better  to  give  the  laxative  two,  or 
even  three,  nights  before  the  operation.  Neither  the  same  laxative 
nor  the  same  dose  should  be  given  to  every  patient  but  the  individual 
intestinal  habit  taken  into  consideration.  Many  a  patient  has  been 
made  uncomfortable  and  the  intestinal  tract  greatly  irritated  by  too 
free  purgation  or  by  the  excessive  or  improper  use  of  enemata  just 
before  being  subjected  to  a  surgical  operation.  My  own  custom  is  to 
find  out  what  laxative  the  patient  has  been  in  the  habit  of  taking  and 
how  it  acts  and  then  to  give  him,  two  nights  before  his  operation,  a 
sufficient  dose  of  this  laxative  to  produce  two  or  three  good  bowel 
movements.  After  most  operations  the  patient  needs  plenty  of  liquid 
and  it  is  a  mistake  to  deplete  a  patient  before  operation  by  producing 
a  number  of  watery  bowel  movements. 

Too  much  attention,  as  a  rule,  is  given  to  the  bowels  and  too  little 
to  the  condition  of  the  mouth  and  nasopharynx.  Even  a  slight  acute 
inflammation  of  the  upper  respiratory  tract  is  too  often  the  cause  of 
postoperative  bronchitis  or  pneumonia.  A  cold  in  the  head  should  be 
looked  upon  as  an  absolute  contra-indication  to  the  administration  of 
any  general  anesthetic  excepting  in  cases  of  the  greatest  urgency.  The 
failure  to  properly  cleanse  the  teeth  and  mouth  before  operation  is  a 
mistake  in  any  operation  which  involves  the  mouth,  pharynx,  esophagus 
and  upper  gastro-intestinal  tract,  as  wound  infection  can  often  be  traced 
to  a  foul  condition  of  the  mouth. 

Nourishment. — After  the  administering  of  the  laxative,  simple 
easily  digested  food  with  plenty  of  water  should  be  given.  Water  alone 
can  be  given  up  to  within  two  or  three  hours  of  the  operation.  The 
free  administration  of  water  supplies  an  element  which  is  badly  needed 
after  the  operation  and  tends  to  prevent  the  distressing  thirst  which 
follows  the  administration  of  an  anesthetic  and  the  loss  of  even  a 
moderate  amount  of  blood. 

Field  of  Operation. — Most  surgeons  have  discontinued  the  use  of 
moist  antiseptic  dressings  over  the  field  of  operation.  This  method 
certainly  renders  the  patient  uncomfortable  and  disturbs  the  rest  which 
he  should  have  prior  to  the  operation.  Antiseptics  applied  in  this  way 
also  tend  to  produce  irritation  of  the  skin  which  adds  to  the  patient's 
postoperative  pain  and  discomfort.  lodin,  if  improperly  employed, 
especially  upon  delicate  skin,  may  cause  blistering  and  even  wound 
infection.  In  order  to  prevent  these  complications,  the  iodin  should 
be  largely  removed  from  the  skin  with  alcohol  at  the  conclusion  of  the 


142  POSTOPERATIVE   TREATMENT 

operation.  Too  vigorous  use  of  strong  antiseptics  on  the  skin  cannot 
be  too  forcibly  condemned. 

The  Urinary  Tract. — Much  of  the  postoperative  trouble  and  dis- 
comfort arising  from  retention  of  urine  can  be  avoided  by  a  little  investi- 
gation and  care  before  the  operation.  The  time  to  discover  that  a 
patient  has  a  stricture,  an  obstructing  h^-pertrophy  of  the  prostate,  or 
a  specific  urethritis  is  before  and  not  after  the  operation.  If  such  con- 
ditions are  relieved  before  the  patient  is  subjected  to  operation,  a  much 
smoother  convalescence  can  be  expected.  While  believing  that  the 
routine  use  of  the  catheter  inmiediately  before  operation  both  unneces- 
sary and  foolish,  I  think  that  when  the  patient  can,  he  should  void 
urine  just  before  the  operation  and,  if  he  is  unable  to  do  so,  the  bladder 
should  be  emptied  by  catheter  at  the  conclusion  of  thejoperation.  If 
this  precaution  is  taken,  it  prevents  the  patient's  bladder  from  becoming 
distended  within  the  first  eight  or  ten  hours  after  operation.  It  also 
enables  us  to  estimate  the  amount  of  urine  secreted  during  the  first 
forty-eight  hours  after  operation  with  some  degree  of  accuracy. 

Patient's  Clothing  and  Position  on  Operating  Table. — There  can  be 
no  question  that  insufficient  clothing  and  exposure  of  the  patient  before 
and  during  the  operation  contribute  not  only  to  postoperative  discom- 
fort but  increase  shock,  lower  resistance,  and  consequently  render 
postoperative  complications  more  likely.  The  too  prevalent  habit 
of  removing  warm  woolen  underclothes,  in  which  the  patient  may 
have  been  in  the  habit  of  sleeping,  and  dressing  him  in  a  thin  cot- 
ton shirt  open  down  the  back,  is  WTong  and  where  it  is  followed  we 
should  not  be  surprised  to  find  our  patients  on  the  day  of  operation 
with  acute  colds  in  the  head.  Exposure  on  the  operating  table  and 
extensive  and  careless  use  of  solutions  over  the  patient's  body  should 
also  be  avoided.  These  solutions  may  be  warm  when  they  are  applied 
but  they  soon  cool  and  the  patient  lies  covered  with  cold  wet  garments. 
It  is  too  often  the  custom  in  abdominal  operations  to  keep  only  the 
legs  of  the  patient  wrapped  in  a  blanket,  allowing  the  chest  to  be  abso- 
lutely exposed  to  air  and  fluids  which  too  soon  become  cool.  A  light 
blanket  or  woolen  shirt  should  always  encase  the  chest.  The  blanket 
which  is  over  the  lower  extremities  should  come  up  as  high  as  pos- 
sible without  interfering  with  the  field  of  operation.  In  other  words, 
only  so  much  of  the  patient  should  be  exposed  on  the  operating  table 
as  is  positively  necessary.  Various  methods  of  keeping  the  patient 
warm  on  the  operating  table  have  been  devised,  such  as  a  rubber 
mattress  containing  hot  water  or  an  electrically  heated  table.  Person- 
ally, I  believe  that  if  the  patient  is  properly  prepared  beforehand,  and 
if  the  surgeon  and  his  assistants  are  careful  not  to  allow  the  clothing 
to  become  saturated  with  fluids,  there  will  be  no  necessity  for  any  of 
these  specially  devised  tables.  If,  on  the  contrary,  it  is  the  surgeon's 
custom  to  use  large  quantities  of  fluids,  then  some  such  method  of 
heating  the  table  is  valuable. 

An  unnatural  position  on  the  table  with  stretching  of  muscles  and 
joints  or  with  pressure  on  superficial  nerve  trunks  may  be  the  cause 


CONDUCT  OF  THE  OPERATION  143 

of  a  great  deal  of  postoperative  suffering.  Some  of  the  unnatural 
positions  into  which  the  body  is  placed  are  necessary  but  they  should 
not  be  maintained  longer  than  absolutely  needed.  IMuch  of  the 
backache  which  the  patient  complains  of  after  operation  is  due  to  the 
position  occupied  on  the  hard  operating  table.  The  perfectly  fiat 
position  is  very  trying,  especially  to  very  stout  patients,  and  it  will  be 
found  that  a  slight  elevation  of  the  head  and  shoulders  and  a  moderate 
flexion  at  the  knees  will  render  the  respiratory  act  much  easier  and  the 
postoperative  backache  less.  The  patient's  arms  should  never  be 
allowed  to  hang  over  the  edge  of  the  table  as  such  a  position  is  liable  to 
result  in  a  musculospiral  palsy  which  will  far  outlast  the  normal  post- 
operative convalescence.  A  further  care  should  be  taken  to  avoid 
blistering  of  the  patient's  skin  by  such  agents  as  benzine,  ether,  etc. 
If  these  agents  are  applied  in  excess,  they  collect  under  the  patient  and, 
if  the  pad  on  the  operating  table  is  covered  with  rubber,  as  it  usually  is, 
quite  severe  blistering  may  occur. 

Conduct  of  the  Operation. — Undue  haste  in  the  performance  of  an 
operation  is  as  bad  as  unnecessary  prolongation  of  it,  the  one  may 
lead  to  injury  of  organs  requiring  additional  operative  procedures 
or  to  some  catastrophe  during  convalescence,  and  the  other  has  to  be 
avoided  as  it  means  the  use  of  much  more  of  the  anesthetic  with  the 
greater  likeliliood  of  the  postoperative  complications  which  result  from 
anesthetics. 

Rough  handling  of  tissues  during  the  performance  of  an  operation  re- 
sults in  the  injury  of  organs,  reduces  their  resistance  to  infection,  causes 
hemorrhage,  increases  shock,  and  interferes  with  healing.  I  have  often 
thought  that  we  would  be  better  surgeons,  would  possess  more  manual 
dexterity  and  skill  and  show  greater  respect  for  the  tissues  we  handle 
if  we  had  to  do  all  our  early  work  with  the  aid  of  local  anesthesia  only. 

If  a  certain  care  is  used  in  the  application  of  ligatures,  much  post- 
operative discomfort  and  in  abdominal  work  occasionally  a  serious 
postoperative  complication  may  be  obviated.  The  ligation  of  large 
masses  of  tissue  should  be  avoided.  I  believe  also  that  as  a  rule  it  is 
better  to  use  small  gut  in  ligating  small  vessels.  Suture  ligatures  are 
much  less  apt  to  become  displaced  than  the  ordinary  ligature.  The  two 
great  objections  to  the  ligation  of  large  amounts  of  tissue  in  the  abdo- 
men are  that  such  ligatures  are  very  apt  to  slip  during  the  subsequent 
manipulation  of  the  tissues  or  after  the  operation  and  that  it  is  more 
difficult  to  cover  the  raw  area  to  which  the  intestine  is  apt  to  become 
adherent  with  a  resulting  obstruction.  ^Yhen  large  masses  of  tissue  are 
included  in  ligatures  passed  on  the  pedicle  needle,  there  is  also  a  risk  of 
including  within  the  ligature  some  important  structure,  such  as  the 
ureter.  The  ligation  of  the  individual  vessels  in  the  broad  ligaments,  in 
the  mesocolon  and  elsewhere  is  a  far  better  plan  than  the  older  method 
of  including  a  large  amount  of  these  structures  in  a  single  ligature  and  is 
followed  by  much  less  likelihood  of  subsequent  adhesion  and  obstruc- 
tion. Too  much  stress  cannot  be  put  on  the  importance  of  avoiding  the 
ligation  of  large  masses  of  omentum,  as  such  are  sure  to  become  adher- 


144  POSTOPERATIVE   TREATMENT 

ent  to  the  intestine  or  to  the  abdominal  wall,  whereas,  if  a  number  of 
ligatm'es  are  placed  the  omentmn  can  be  restored  to  the  abdomen 
and  spread  out  in  a  fashion  somewhat  like  the  normal. 

A  common  fault  in  technic  is  the  too  tight  constriction  of  tissues  with 
sutures.  This  not  only  applies  to  the  skin,  but  to  deeper  structures. 
It  should  be  borne  in  mind  that  all  that  is  required  is  a  comfortable 
approximation.  Sutures  too  tightly  placed  interfere  with  circulation, 
produce  necrosis,  and  lower  resistance  to  infection.  If  the  suture 
material  is  silk  or  linen  thread,  the  too  tight  constriction  of  the  tissues 
results  in  cutting  and  the  primary  object  of  the  suture  is  thwarted. 
Many  accidental  wounds,  such  as  lacerations  of  the  scalp,  are  made  to 
suppurate  by  the  too  close  and  the  too  tight  introduction  of  sutures. 
In  the  accident  wards  of  our  hospitals  it  would  be  much  better  to  pro- 
vide the  interne  with  horse  hair  alone  as  a  skin  suture,  as  it  is  so  delicate 
that  too  tight  tying  is  impossible. 

The  care  and  position  of  the  drainage  which  may  be  necessary  in 
an  operation  has  an  important  postoperative  bearing,  especially  in 
abdominal  work.  Personally  I  am  inclined  to  believe  that  it  is  only  in 
exceptional  cases  that  rigid,  inflexible  drainage  tubes  should  be  used, 
since  by  pressure  they  may  cause  ulceration,  especially  when  introduced 
into  a  mucous-lined  cavity  and  often  are  responsible  for  persistent  reflex 
vomiting.  Such  tubes  also  may  be  the  cause  of  intestinal  obstruction. 
\Mienever  a  drainage  tube  is  introduced  into  a  mucous-lined  cavity, 
care  should  be  taken  to  see  that  the  end  of  the  tube  does  not  make 
pressure  on  the  wall  of  the  cavity;  to  drain  such  organs  as  the  gall- 
bladder it  is  only  necessary  to  have  the  tube  extend  into  the  cavity  for  a 
short  distance.  Tubes  should  always  be  fixed  by  suture  or  some  other 
means  so  that  they  cannot  slip  either  in  or  out.  This  applies  not  alone 
to  abdominal  drains,  but  to  all,  and  particularly  to  those  of  the  chest 
wall.  Uncovered  gauze  drains  possess  very  serious  disadvantages,  the 
greatest  of  which  is  the  disposition  of  the  tissue  to  become  firmly 
attached  to  them,  thus  interfering  with  drainage  to  some  extent  and 
rendering  their  removal  difficult  and  very  painful.  Unless  there  is 
sufficient  discharge  from  the  wound  to  keep  the  draiij  moist,  it  is  sure 
to  become  adherent  at  its  exit  from  the  wound  and  acts  then  more  as  a 
plug  than  a  drain.  Large  unprotected  gauze  drains  in  the  abdominal 
cavity  also  produce  adhesions  which  often  result  in  subsequent  obstruc- 
tion. Because  of  the  capillary  quality  of  the  gauze  drain  when  placed 
against  a  closed  organ,  such  as  the  intestine,  common  duct,  renal 
pelvis,  ureter,  etc.,  it  invites  leakage.  When  covered  with  gutta-percha 
or  thin  rubber  dam  in  such  a  way  as  to  leave  the  gauze  exposed  only  at 
the  extremity  of  the  drain  or  through  small  openings  on  the  side,  the 
drain  at  once  possesses  all  the  advantages  of  the  tube  and  gauze  drains 
and  many  of  their  disadvantages  are  obviated.  It  is  true  that  these 
drains  tend  to  slip  about  and  may  not  remain  in  just  the  situation  that 
the  surgeon  would  like  and  therefore  they  should  always  be  fixed  with 
a  light  catgut  suture  in  the  desired  position.  As  a  general  rule  it  is 
well  to  let  the  drain,  of  whatever  character  employed,  pass  out  through 


DRESSINGS  145 

that  part  of  the  wound  where  it  naturally  falls  instead  of  carrying  it  to" 
one  or  the  other  extremity  of  the  wound ;  this  is  particularly  important 
where  it  is  known  that  the  re-introduction  of  a  drain  will  be  necessary 
later. 

All  drains  should  be  fixed  at  their  exit  through  the  skin  by  a  suture, 
safety-pin  or  some  other  device  which  will  prevent  any  shifting  of  the 
drain. 

Dressings. — In  regard  to  the  material  used  in  dressing  wounds  and 
the  method  of  holding  them  in  position,  there  will  probably  never  be 
any  fixed  rule,  but  it  is  not  out  of  place  in  this  connection  to  speak  in  a 
general  way  of  both. 

In  all  clean  wounds  the  dressing  should  be  dry  and  gauze  is  the 
material  commonly  used.  Zinc  oxide  adhesive  strips  are  generally 
employed  for  the  fixation  of  the  dressing,  but  care  should  be  taken  not 
to  apply  these  strips  to  skin  covered  by  hair  or  to  skin  recently  painted 
with  iodin,  unless  the  iodin  has  been  thoroughly  removed  with 
alcohol,  neither  should  the  strips  be  applied  so  tightly  as  to  interfere 
with  normal  movement  of  the  underlying  muscles,  unless  such  inter- 
ference is  desired.  The  adhesive  strips  should  not,  as  a  rule,  overlap 
one  another  but  an  area  of  uncovered  skin  should  be  left  between  them. 
Wrinkling  or  pinching  of  the  skin  should  also  be  avoided.  We  often 
make  the  mistake  in  applying  the  dressings  after  an  operation  of  plac- 
ing the  parts  in  abnormal  positions,  which  is  only  occasionally  neces- 
sary and  which  results  in  a  great  deal  of  postoperative  discomfort.  The 
old  method  of  fixing  the  arm  to  the  chest  wall  after  a  breast 'amputation 
with  a  tight  binder  or  bandage  is  as  good  an  illustration  as  I  could  give 
of  the  point  I  would  make,  since  the  position  is  unnecessary  and  gives 
rise  to  the  greatest  pain  and  discomfort,  especially  at  the  elbow.  Very 
often  in  the  use  of  splints  and  casts  the  bony  prominences  and  nerves 
are  not  sufficiently  protected  from  pressure  and  the  patient  conse- 
quently suffers  an  unnecessary  amount  of  pain  and  he  may  suffer  for 
weeks  after  the  healing  of  the  wound  or  injury  from  pressure  ulcerations 
or  from  palsies;  it  is  only  necessary  to  refer  to  pressure  ulcerations 
over  the  internal  condyle  of  the  humerus,  over  the  heel  and  to  Volk- 
man's  contracture  and  to  paralysis  of  the  perineal  nerve  due  to  pressure 
below  the  knee.  We  have  often  seen  patients  spend  days  and  nights  with 
pain  and  discomfort  due  to  a  too  tightly  applied  spica  of  the  hip.  This 
bandage  is  frequently  applied  improperly  by  an  orderly  while  the 
patient  is  still  anesthetized  and,  the  only  position  which  will  relieve  the 
tension,  that  of  flexing  the  thighs  on  the  abdomen,  is  denied  the  patient 
by  a  too  careful  nurse.  A  complaint  on  the  part  of  a  patient  on  recovery 
from  an  anesthetic  of  pain,  especially  at  a  distance  from  the  wound,  and 
of  tightness  or  constriction  of  the  bandage,  or  of  a  burning  tingling  pain 
at  the  site  of  a  bony  prominence  requires  inspection  of  the  dressing  and 
often  the  entire  removal  and  re-application  of  the  bandage,  the  splint, 
or  the  cast. 


VOL.  I. 10 


146  POSTOPERATIVE   TREATMENT 

IMMEDIATE  CARE  AFTER  OPERATION. 

As  far  as  possible. the  postoperative  care  should  consist  largely  in 
making  the  patient  comfortable  and  seeing  that  he  does  nothing  which 
will  disturb  the  normal  healing  of  his  wound  and  in  aiding  where 
necessary  the  reestablishment  of  normal  functions. 

Immediately  after  operation,  that  is  from  the  time  the  patient  leaves 
the  operating  table  until  he  has  entirely  regained  consciousness,  he 
should  be  constantly  watched  by  a  nurse  or  physician  who  is  capable  of 
preventing  or  dealing  with  any  of  the  simpler  difficulties  which  may 
arise  in  a  patient  recovering  from  an  anesthetic  and  of  recognizing 
early  the  symptoms  of  hemorrhage,  suffocation  or  collapse.  Even 
after  the  simplest  operation  a  competent  surgical  assistant  or  the 
surgeon  himself  should  be  within  easy  call  in  case  of  emergency. 

Restraint  and  Position. — The  patient  should  be  allowed  such 
freedom  of  movement  or  position  as  will  not  disturb  the  wound  or 
dressing.  Too  often  patients  are  restrained  from  the  simplest  move- 
ment and  made  to  lie  absolutely  quiet  on  the  back  when  such  restraint 
is  not  in  the  least  necessary  and  only  adds  to  their  discomfort  and 
makes  them  either  rebellious  or  needlessly  apprehensive.  One  often 
sees  a  patient  who  habitually  sleeps  with  two  or  three  pillows  made 
absolutely  miserable  by  being  compelled  to  lie  flat  on  his  back  with  no 
pillow  at  all.  In  the  early  days  of  abdominal  surgery  this  restraint 
was  rigidly  carried  out,  the  patient  not  even  being  allowed  to  move  a 
leg  and  the  after-treatment  was  a  torture.  It  is  often  better  to  allow 
the  patient  to  try  an  attitude,  which  you  know  will  be  painful  or  uncom- 
fortable and  let  him  discover  for  himself  that  it  is  not  advisable,  for 
in  this  way  he  is  resigned  to  the  necessary  limitation  of  movement.  In 
many  cases  a  change  of  position  such  as  the  legs  flexed  on  a  pillow, 
slight  elevation  or  lowering  of  the  head,  a  hand  on  top  of,  instead  of 
under,  the  bed  clothes,  or  turning  on  the  side  produces  a  degree  of 
comfort  and  satisfaction  which  only  morphin  can  produce.  Whenever 
a  patient  wishes  to  assume  his  accustomed  attitude  of  rest  in  bed,  he 
should  be  allowed  to  do  so  unless  the  character  of  the  wound  or  oper- 
ation forbids  it. 

Patients  are  always  restless  after  an  anesthetic  unless  morphin  has 
been  given  and  at  times  may  be  difficult  to  control.  Forcible  restraint 
of  a  patient,  is  a  mistake  as  a  rule  and  should  be  avoided  if  possible. 
Often  a  patient  will  quiet  do^\TL  if  his  attention  can  be  diverted  and 
he  realizes  his  surroundings.  As  soon  as  a  patient  recovers  from  an 
anesthetic  he  should  be  assured  that  everj-thing  is  all  right  and  that  he 
is  in  good  condition.  Such  assurances  will  usually  satisfy  him  and 
if  it  is  not  given  in  response  to  his  inquiries,  his  anxiety  is  naturally 
increased.  An  intelligent  and  s^inpathetic  nurse  at  this  time  is  far 
more  valuable  than  the  patient's  friends  and  relatives  who  are  too  apt 
to  misinterpret  his  restlessness  and  reveal  to  the  patient  himself  their 
own  anxiety. 

The  Fowler  position  is  so  generally  understood  at  the  present  that 


NAUSEA  AND  VOMITING  147 

no  description  of  it  or  illustration  seems  necessary.  It  should  be  under- 
stood, however,  that  this  position  cannot  be  comfortably  maintained 
without  one  of  the  variously  constructed  supports  which  are  placed 
either  under  or  on  top  of  the  mattress.  A  few  surgeons  of  wide  experi- 
ence do  not  look  with  favor  on  this  posture,  but  it  is  used  in  cases  of 
peritonitis  in  a  large  majority  of  clinics. 

Artificial  Heat. — Artificial  heat  in  the  form  of  hot-water  bags  and 
hot-water  tins  can  I  think  be  overdone  and  of  course  if  not  properly 
employed  can  give  rise  to  the  most  distressing  burns.  What  a  patient 
requires  after  an  anesthetic  of  any  length  is  warmth  and  protection 
from  draughts  while  perspiration  is  active.  Too  much  heat  either  in 
the  shape  of  hot-water  bags  or  blankets,  I  am  convinced  frequently  is 
the  cause  of  continued  sweating.  As  far  as  possible  the  skin  of  the 
patient  should  be  kept  dry  and  warm.  A  cold  clammy  skin,  especially 
when  accompanied  by  restlessness,  anxiety,  and  a  rapid  small  pulse,  is 
of  course  significant  of  hemorrhage  and  presents  a  very  different  picture 
from  that  of  the  ether  delirium  and  profuse  sweat  seen  immediately 
after  an  operation. 

Nausea  and  Vomiting. — Nausea  and  vomiting  is  a  more  or  less 
constant  sequel  of  operation,  especially  of  abdominal  operations.  We 
are  prone  to  boast  that  with  our  individual  method  of  inducing  anes- 
thesia and  of  conducting  our  operations  that  the  patient  has  "prac- 
tically no  nausea,"  but  this  is  an  indefinite  and  often  untrue  statement. 
Although  the  anesthesia  is  responsible  to  a  large  extent  for  the  nausea, 
it  is  not  altogether  so  for  we  sometimes  see  distressing  nausea  after  an 
abdominal  operation  performed  under  infiltration  anesthesia.  Internes 
and  internist  are  far  too  prone  to  give  drugs  or  drinks  for  the  purpose  of 
arresting  nausea  and  vomiting  and  the  patient  and  his  friends  beg  for 
something  to  "settle  the  stomach;"  drugs  in  this  early  stage  are  much 
more  apt  to  aggravate  it.  A  far  better  plan  is  to  give  nothing  or  else 
a  full  glass  of  water,  which  is  usually  promptly  vomited  with  some 
relief. 

Care  should  be  taken,  especially  after  those  emergency  operations 
where  there  has  been  no  opportunity  to  prepare  the  patient  for  an 
anesthetic,  to  see  that  none  of  the  vomited  material  obstructs  the 
pharynx  or  is  inspired.  My  experience  in  using  morphin  and  atropin 
in  abdominal  cases  has  shown  vomiting  to  be  so  much  less  than  in  other 
operations  in  which  it  was  not  employed  that  I  now  use  it  in  every 
operation  of  magnitude  or  long  duration  or  those  which  I  expect  to  be 
followed  by  much  pain.  It  is  seldom  necessary  to  give  a  second  dose, 
and  this  I  try  particularly  to  avoid,  for  it  is  better  not  to  let  the  patient 
learn  the  comfort  of  morphin.  Repeated  small  doses  after  operation 
do  not  appeal  to  me,  because  the  patient  is  apt  to  become  dependent 
upon  it.  When  the  single  full  dose  is  given  before  the  anesthetic,  the 
patient  will  often  sleep  for  from  one  to  three  hours  and  remain  quiet 
for  a  much  longer  period. 

Pain  developing  some  hours  after  an  operation  is  not  to  be  treated  by 
the  immediate  administration  of  an  anodyne,  but  its  cause  should  be 


148  POSTOPERATIVE   THE  AT. ME  XT 

carefully  sought  and  removed.  A  careful  and  considerate  nurse  can  do 
much  to  relieve  such  pain.  Oftentimes  the  simple  change  of  posture,  the 
cutting  of  a  tight  bandage,  the  relief  of  pressure  on  some  bony  promi- 
nence, straightening  out  the  clothing,  or  some  such  little  attention  will 
give  relief.  I  have  seen  a  patient  kept  awake  all  night  by  pressure  on  the 
heel  after  a  fracture  of  the  leg,  and  by  pressure  on  the  internal  condyle  by 
an  internal  angular  splint.  Pain  under  such  cu'ciunstances  is  absolutely 
unnecessary,  and  its  possible  cause  should  always  be  considered.  I 
have  known  a  safety-pin  to  be  passed  through  the  patient's  skin  in 
fixing  a  bandage  and  to  remain  in  this  position  for  days.  Therefore, 
instead  of  attributing  the  patient's  complaint  of  pain  to  nervousness 
or  to  want  of  pluck,  we  should  always  make  sure  that  there  is  not  some 
actual  cause  for  the  complaint. 

Thirst.  —  After  all  operations,  but  particularly  after  abdominal 
operations,  thirst  is  an  early  complaint  and  one  which  I  believe 
should  be  satisfied  by  giving  water  by  the  mouth,  unless  it  is  contra- 
indicated  and  in  such  cases  by  the  rectum.  If  the  patient  is  vom- 
iting, he  may  be  given  a  glass  of  hot  water  which  as  mentioned 
before  will  result  in  a  fair  gastric  lavage.  It  is  only  where  vomiting  is 
persistent,  in  certain  operations  on  the  stomach  itself,  and  in  cases  of 
peritonitis  that  water  by  the  mouth  should  be  forbidden.  Unless  given 
with  the  idea  of  washing  out  the  stomach,  I  think  that  cold  water  is 
preferred  by  most  patients  and  I  usually  allow  the  patient  the  choice. 
If  an  operator  does  not  believe  in  giving  the  patient  water  to  drink,  he 
certainly  should  give  large  quantities  slowly  by  the  rectum. 

Diet. — The  very  old  and  the  very  young  patients  require  earlier 
feeding  after  an  operation  than  others  and  it  seems  to  do  them  no 
harm.  As  a  general  rule  a  desire  for  food  should  precede  its  adminis- 
tration. It  is  a  mistake  to  urge  food  upon  any  healthy  patient  soon 
after  an  operation,  unless  he  really  wants  it.  Water  in  good  quantities 
is  all  the  patient  needs  in  the  majority  of  instances  during  the  first  day 
or  two,  or  albumen  water  with  orange  juice  or  orange  juice  alone  may 
be  given. 

In  regard  to  the  liquid  feeding,  the  patient's  choice  and  habit  should 
be  considered,  as  for  instance,  a  patient  who  is  accustomed  to  drinking 
tea  should  have  tea  and  not  be  forced  to  drink  milk. 

The  return  to  a  full  liberal  diet  should  be  gradually  brought  about 
by  following  the  liquid  nourislmient  with  cup  custards,  ice-cream,  soft 
boiled  eggs,  etc.  Spinach  is  a  vegetable  which  is  particularly  useful 
after  operation  because  it  tends  to  produce  movement  of  the  bowels. 
Only  easily  digested  and  no  rich  food  should  be  given  to  the  patient 
the  first  week  or  two  following  operation  and  thorough  mastica- 
tion should  be  insisted  upon.  Smoking,  if  habitual  with  a  patient, 
should  be  allowed  as  soon  after  operation  as  desired,  as  it  produces 
a  sense  of  comfort.  The  first  request  of  a  French  soldier  during 
the  late  war  after  operation  was  for  a  cigarette  and  it  was  always 
allowed  him. 

Rectal  feeding  must  often  be  depended  upon  after  operation  and 


BLADDER  149 

I  believe  that  little  else  than  peptonized  or  malted  milk  with  eggs 
should  be  given.  Alcohol  in  any  form,  if  long  continued,  produces  an 
irritation  of  the  rectum  and  an  intolerance  for  the  nutrient  enema. 

Bowels. — One  of  the  mistakes  of  the  past  and  still  too  often  made 
is  that  of  the  excessive  and  too  early  administration  of  laxatives  after 
operation.  If  the  patient  has  been  properly  prepared  for  operation 
and  has  taken  only  liquid  food,  the  administration  of  any  laxative 
within  the  first  few  days  after  an  abdominal  operation  accomplishes 
very  little  good  and  adds  enormously  to  the  patient's  discomfort  and 
loss  of  sleep.  The  "gas  pains"  which  patients  complain  of  after  oper- 
ation are  not  really  due  to  gas,  but  to  peristalsis  and  to  increase  this 
perstalsis  with  a  laxative,  when  the  intestinal  tract  is  comparatively 
empty,  does  more  harm  than  good.  A  small  enema  or  the  introduction 
of  the  rectal  tube  will  accomplish  more  good  and  give  rise  to  little  dis- 
comfort. When  it  does  become  necessary  to  give  a  laxative,  it  should 
be  of  a  mild  character.  For  some  years  I  have  found  that  one  of  the 
preparations  of  mineral  oil  is  very  satisfactory.  Milk  of  magnesia  is 
another  useful  mild  laxative  in  these  cases.  Of  course  occasionally 
when  a  patient  has  not  been  prepared  for  operation,  a  thorough  opening 
of  the  bowels  is  a  good  thing,  but  to  routinely  administer  a  laxative  on 
the  second  day  after  an  operation  as  was  formerly  the  custom,  is  a 
great  mistake. 

Bladder.^ — Many  patients  have  difficulty  in  voiding  urine,  especially 
after  abdominal  operations  and  those  done  on  the  perineum  and  rectum. 
Excepting  those  cases  where  contamination  of  the  wound  is  feared, 
every  effort  and  means  should  be  employed  to  make  the  patient  pass  his 
own  urine  and  to  avoid  the  use  of  the  catheter.  The  patient  should 
even  be  allowed  to  stand  on  his  feet  beside  the  bed  in  order  to  void, 
unless  such  a  position  is  apt  to  interfere  with  the  integrity  of  the  wound 
closure  and  female  patients  should  always  be  allowed  to  sit  up  on  a 
bed-pan  rather  than  be  catheterized.  Too  frequently  the  catheter  is 
passed  when  the  patient  has  had  no  discomfort  and  there  is  no  evidence 
of  distention  of  the  bladder  and  it  is  done  simply  because  the  patient 
has  not  voided  within  eight  or  ten  hours  after  operation.  It  should  be 
borne  in  mind  that  patients  often  secrete  very  little  urine  during  the 
first  few  hours  after  operation  and,  when  once  the  catheter  has  been 
used,  there  is  a  great  likelihood  of  it  having  to  be  used  again.  If  a 
patient  voids  once,  he  should  be  able  to  void  afterward  and  the  catheter 
should  not  be  used  unless  absolutely  necessary  because  of  distention. 
The  administration  of  an  enema  very  frequently  enables  the  patient  to 
void  and  in  rectal  cases  inability  to  do  so  is  due  to  too  tight  packing  of 
the  wound  or  to  the  presence  of  a  tube  or  tampon  in  the  rectum  and 
their  removal  will  bring  about  a  normal  micturition. 

If  a  patient  has  urethritis,  the  passage  of  the  catheter  is  strongly 
contra-indicated  as  it  is  sure  to  result  in  an  extension  of  the  infection. 
One  of  the  strong  arguments  against  the  use  of  the  catheter  is  the  danger 
of  infection  and  an  irritation  of  the  urethra  from  continued  catheteri- 
zation.  When  catheterization  is  absolutely  necessary,  it  should  not  be 


150  POSTOPERATIVE  TREATMENT 

done  I  believe  at  regular  intervals,  but  when  the  patient  becomes 
uncomfortable  because  of  a  full  bladder.  We  have  all  seen  patients 
suffer  great  torture  because  the  stipulated  number  of  hours  between 
catheterizations  had  not  yet  expired.  Nothing  is  more  imcomfortable 
to  a  patient  who  has  been  operated  upon  than  a  distended  bladder 
and  no  one  can  predict  in  any  given  case  the  number  of  hours  required 
to  bring  about  an  uncomfortable  distention.  As  a  rule  a  patient  is 
more  apt  to  pass  urine  before  the  bladder  becomes  greatly  distended 
and  it  is  at  this  time  that  he  or  she  should  be  encouraged  to  do  so.  The 
character  of  the  urine  and  the  amount  passed  should  be  as  carefully 
determined  after  the  operation  as  before  it. 

Pulse,  Temperature  and  Respiration. — In  determining  the  value  of 
these  after  an  operation,  it  is  important  to  have  a  record  of  them  a  day 
or  two  previous  to  operation.  Nurses  should  be  instructed  always  to 
feel  and  count  both  radial  pulses,  as  often  one  of  these  vessels  is  much 
larger  than  the  other. 

The  significance  of  the  pulse,  temperature  and  respirations  in  shock 
and  hemorrhage  are  dealt  with  so  completely  in  the  chapters  dealing 
with  these  subjects  that  it  is  unnecessary  to  mention  it  here.  Axillary 
temperature  after  an  operation  is  not  very  reliable  and  where  there  is  an 
unexplained  difference  in  the  mouth  and  axillary  temperature,  it  should 
be  confirmed  by  a  rectal  thermometer.  An  increased  respiratory  rate 
is  not  given  the  consideration  in  surgical  cases  that  it  deserves  and 
when  it  is  not  in  proportion  to  pulse  and  temperature  or  is  not  explained 
by  the  character  of  the  operation,  it  usually  means  some  inflammatory 
condition  in  the  lung  or  pleura  or  it  may  indicate  an  acidosis. 

Time  in  Bed. — No  definite  rule  can  be  laid  down  as  to  the  number 
of  days  a  patient  should  stay  in  bed  after  an  operation.  In  the  early 
days  of  abdominal  surgery,  too  much  restraint  was  put  on  a  patient  in 
this  way  and  every  other  way,  and  a  few  years  ago  there  was  a  move- 
ment which  went  too  far  in  the  other  direction  and  resulted  in 
wound  infection  and  other  complications. 

The  question  is  not  how  soon  the  patient  can  get  out  of  bed,  but  how 
soon  should  he  do  so.  Generally  speaking  he  should  remain  in  bed  until 
his  wound  is  healed,  if  it  should  be  an  abdominal  wound,  and  if  it  is  a 
large  abdominal  wound  he  should  remain  in  bed  at  least  a  week  after 
it  has  healed. 

CARE  AFTER  RECOVERY  FROM  OPERATION. 

INIany  of  our  finest  surgical  results  are  spoiled  by  a  lack  of  care  after 
the  patient  has  left  the  hospital  and  simply  because  he  has  not  been 
told  what  he  should  and  should  not  do  or  has  not  received  the  late 
postoperative  treatment  which  he  requires. 

What  would  be  the  results  in  our  cases  of  exophthalmic  goiter  if  no 
attention  were  paid  the  patients  after  operation? 

I  should  say  the  two  conditions  most  neglected  after  the  operation 
were  tuberculosis  and  syphilis.    The  results  of  surgical  interference  in 


COMPLICATIONS  AFTER  OPERATIONS  151 

localized  tuberculosis  are  remarkably  good  and  the  patients  usually 
make  complete  recoveries,  if  they  carry  out  the  proper  hygienic, 
dietetic  and  medicinal  treatment  after  operation.  If  these  measures 
are  not  enforced,  there  is  a  fair  chance  of  recurrence  of  the  trouble  or  its 
development  somewhere  else.  S}'philitic  patients  are  too  frequently 
operated  upon  and  no  instruction  given  them  as  to  their  subsequent 
treatment.  The  same  applies  to  operations  for  malignant  disease;  the 
use  of  the  .r-rays  after  operations  for  cancer,  and  the  use  of  the  .r-rays  or 
radium  with  Coley's  toxins  after  operations  for  sarcoma  have  resulted  in 
many  cures  that  would  have  never  been  obtained  through  operation  only. 
jNIost  sm'geons  are  too  busy  to  carry  out  these  postoperative  treatments, 
but  the  responsibility  of  seeing  that  the  treatment  is  carried  out  is  theirs. 
Another  important  thing  after  operation  and  one  generally  neglected 
by  surgeons  is  some  plan  of  following  up  the  patient  in  order  to  record 
the  result  obtained.  Such  a  plan  does  more  to  destroy  self-satisfaction 
on  the  part  of  the  surgeon  and  stimulate  him  to  better  efforts  than 
anything  else. 

COMPLICATIONS  AFTER  OPERATIONS. 

Hemorrhage  and  Shock. — Hemorrhage  and  shock,  two  serious  but 
fortunately  not  common  sequels  of  operation  have  been  considered  in 
other  sections  of  this  work  and  it  is  needless  to  speak  of  them  again. 
(Pages  117-124.) 

Abdominal  Distention. — Abdominal  distention  of  some  degree  is 
common  after  abdominal  operations  but  may  occur  after  any  operation 
or  after  an  injury,  such  as  a  broken  leg  or  the  laceration  of  a  kidney. 

The  postoperative  distention  may  be  due  to  a  simple  accumulation 
of  gas  in  the  intestinal  tract,  the  result  of  fermentation  or  the  swallow- 
ing of  air,  to  a  paralytic  ileus,  to  an  obstruction  of  the  bowels  (mechani- 
cal or  septic)  or  to  acute  dilatation  of  the  stomach.  The  simple  tj-pe 
of  moderate  distention  is,  as  a  rule,  easily  relieved  by  the  use  of  the 
rectal  tube,  change  of  position,  the  administration  of  a  carminative  or 
the  use  of  an  enema  and  as  the  emplo^ixient  of  these  agents  has  been 
dealt  with,  it  is  needless  to  consider  them  again,  but  the  distention 
resulting  from  the  other  causes  mentioned  deserves  more  serious 
t;onsideration. 

Paralytic  Distention. — Paralytic  distention  is  not  always  due  to  a 
peritonitis  as  some  would  have  us  believe  but  should  be  distinguished 
from  that  form  of  intestinal  obstruction  due  to  peritonitis.  We  see 
the  paralysis  of  peristalsis  after  operations  on  the  kidney  where  the 
peritoneum  has  been  subjected  to  only  the  slightest  traumatism  and 
after  injuries,  especially  in  strong  muscular  individuals  and  in  the  aged, 
when  rest  in  the  recumbent  position  is  necessary,  and  in  many  other 
conditions.  Although  in  the  majority  of  cases  the  distention  can  be 
relieved  in  the  beginning  by  simple  means  if  it  lasts  for  any  length  of 
time  it  becomes  very  distressing  and  possibly  serious.  In  the  post- 
operative cases  it  comes  on  early  and  is  accompanied  by  vomiting.    Its 


152  POSTOPERATIVE  TREATMENT 

distinctive  feature  is  an  absence  or  marked  lessening  of  peristalsis. 
There  is  often  great  difficulty  in  differentiating  this  condition  from  an 
ileus  due  to  peritonitis  but  the  patient  does  not  show  the  other  symp- 
toms of  peritonitis  and  the  distention  of  a  peritonitis  is  a  late,  not  an 
early  s\Tnptom,  after  operation,  unless  the  peritonitis  was  present  at 
the  time  of  the  operation. 

Where  there  is  a  doubt  as  to  the  cause  of  the  obstruction,  that  is, 
when  a  peritonitis  or  a  mechanical  obstruction  is  suspected,  the 
treatment  of  these  conditions,  which  is  given  later,  should  be  followed, 
and  not  that  to  be  outlined  now. 

Where  one  can  be  sure  then  that  a  mechanical  obstruction  or  a 
peritonitis  is  not  present  relief  of  the  distention  may  be  obtained  by 
attempting  to  stir  up  peristalsis  by  the  administration  of  drugs  and  by 
the  use  of  enemata.  Local  applications  such  as  turpentine  stupes  or 
flax-seed  poultices  often  give  comfort  and  cause  the  passage  of  flatus. 
Enemata  of  soap  and  water  with  turpentine,  given  high,  in  good 
quantity  are  indicated.  An  asafetida  enema  I  am  sure  I  have  seen 
give  relief  although  its  efficacy  is  doubted  by  many.  The  rectal  tube 
or  nozzle  left  in  position  for  several  hours,  especially  with  the  patient 
on  his  left  side,  when  this  position  is  not  contra-indicated,  is  of  the. 
greatest^  service. 

Among  the  drugs  employed  in  this  condition  are  strychnin,  eserin 
and  pituitrin.  The  ordinary  purgatives  often  only  increase  the  con- 
tents of  the  intestine  by  causing  secretion  from  the  mucous  membrane 
and  do  little  to  produce  peristalsis.  I  have  used  eserin  but  confess  that 
I  have  not  been  impressed  with  its  power.  Pituitrin  will  certainly 
increase  peristalsis  and  I  have  seen  it  cause  a  rapid  subsidence  of  a 
distended  abdomen  following  a  nephrotomy.  I  should  not  use  either 
of  the  two  latter  drugs  for  a  distention  coming  on  after  forty-eight 
hours  after  an  abdominal  operation  for  fear  of  aggravating  a  peri- 
tonitis or  an  obstruction  due  to  a  mechanical  cause.  Too  much  stress 
cannot  be  laid  on  the  importance  of  eliminating  these  two  conditions 
before  resorting  to  any  measure  which  will  increase  peristalsis.  C.  L. 
Gibson'  strongly  recommends  pituitrin.  He  urges  a  fresh  preparation 
and  advises  "an  ampoule  (1  c.c.)  of  the  preparation  and  repeat  every 
hour  up  to  three  doses;  subsequent  doses  two  hours  apart." 

The  old  method  of  attempting  to  relieve  paralytic  distention  by 
puncturing  the  bowel  through  the  abdominal  wall  is  certainly  always 
dangerous  and  practically  never  efficacious.  Even  the  opening  of  the 
abdomen  and  establishment  of  an  artificial  anus  will  as  a  rule  only 
relieve  the  distention  of  two  or  three  feet  of  intestine,  although  this  is 
a  far  safer  plan  than  puncturing  the  bowel  through  the  abdominal 
wall,  which  is  no  longer  a  justifiable  procedure. 

Postoperative  Intestinal  Obstruction. — This  distressing  complica- 
tion is  not  as  frequent  as  formerly,  due  to  the  development  of  a  more 
careful  technic  and  the  observance  of  those  precautions  to  pre^■ent  it 

1  Ann.  Surgery,  April,  19)6. 


COMPLICATIONS  AFTER  OPERATIONS  153 

which  have  aheady  been  repeatedly  referred  to,  particularly  the 
avoidance  of  rough  handling  of  tissues  and  the  covering  over  of  raw 
areas  with  peritoneum  and  omentum,  because  it  is  adhesions  which  con- 
stitute the  chief  cause  of  postoperative  obstruction.  Of  course  the 
cause  of  the  obstruction  may  have  existed  before  operation,  such  as  a 
septic  peritonitis,  or  may  be  unavoidable  during  the  operation  owing 
to  a  necessarily  extensive  procedure,  such  as  the  removal  of  a  large 
portion  of  the  colon  or  a  large  adherent  tumor. 

Mechanical  Obstruction. — In  this  type  there  is  definite  mechanical 
pressure  exerted  upon  the  intestine  which  first  prevents  the  passage 
of  the  intestinal  contents  and  later  produces  either  gangrene  of 
the  intestine  or  peritonitis  or  both.  Adhesions  certainly  cause  the 
majority  of  the  mechanical  postoperative  obstructions  and  the  most 
potent  t}n^e  is  the  adhesion  of  the  small  intestine  to  some  fixed  point, 
such  as  the  abdominal  or  pelvic  wall,  the  raw  surface  of  a  broad  liga- 
ment, the  uterine  stump  and  the  mesentery.  One  constantly  sees 
numerous  coils  of  small  intestine  bound  together  by  the  densest 
adhesions  and  yet  no  obstruction  results.  The  degree  of  mobility  of 
the  structure  to  which  the  intestine  is  adherent  then  strongly  deter- 
mines the  development  of  obstruction.  It  may  be  said  in  this  con- 
nection that  the  surgeon  is  frequently  surprised  on  opening  an  abdomen 
a  second  time  to  find  that  nature  has  done  away  with  many  adhesions 
which  were  present  at  the  first  operation  and  if  this  were  not  true,  the 
number  of  obstructions  w^ould  be  greatly  increased.  It  is  also  a  com- 
mon observation  that  a  severe  and  extensive  infection  of  short  duration 
gives  rise  to  few^er  permanent  and  obstructing  adhesions  than  a  more 
localized  or  milder  infection  requiring  prolonged  drainage.  Drainage 
itself  in  the  absence  of  infection  is  a  frequent  cause  of  obstructing 
adhesions.  This  was  seen  frequently  in  the  early  days  of  abdominal 
surgery  W'hen  drainage  was  employed  after  all  operations. 

Symptoms. — ^The  symptoms  of  the  mechanical  obstruction  are  often 
insidious  and  rarely  appear  before  the  fifth  or  sixth  day  after  operation 
and  often  not  until  much  later.  The  first  complaint  is  usually  of 
paroxysmal  pain  and  difficulty  in  satisfactorily  emptying  the  bowels; 
this  is  followed  by  vomiting  if  the  obstruction  is  high  or  distention  if  it 
is  low.  Vomiting  develops  later  regardless  of  the  situation  of  the 
obstruction,  but  distention  may  not  be  marked  if  the  obstruction  is 
high  up  in  the  small  intestine.  Visible  peristalsis  with  distention  is 
absolutely  indicative  of  mechanical  obstruction.  It  is  quite  evident 
too  that  the  sharp  paroxysmal  pain  is  caused  by  peristalsis. 

The  patient  may  be  relieved  in  the  early  stages  by  a  move- 
ment of  the  bowels  or  the  passage  of  a  large  quantity  of  gas  but  the 
symptoms  are  apt  to  recur  and  if  they  do,  it  is  another  indication 
of  some  mechanical  obstruction,  but  it  may  not  be  so  easily  relieved 
as  in  the  first  instance.  After  the  onset  of  the  symptoms  it  is  not  at  all 
infrequent  to  have  a  copious  movement  follow  an  enema  or  consider- 
able gas  escape  through  a  rectal  tube,  but  if  this  does  not  relieve  the 
pain,  diminish  the  distention  and  arrest  the  vomiting,  it  is  evident  that 


154  POSTOPERATIVE   TREATMENT 

the  fecal  matter  and  gas  have  come  from  the  bowel  beyond  the  point 
of  obstruction.  One  then  must  not  be  misled  by  the  mere  fact  that  a 
movement  or  the  expulsion  of  gas  has  followed  the  emplo\Tnent  of  an 
enema  or  the  introduction  of  the  tube. 

Septic  Obstruction.- — In  this  type  of  intestinal  obstruction  the  cause 
is  a  septic  infection  of  the  peritoneum  and  the  obstruction  is  paralytic 
or  adynamic.  It  comes  on  early  after  operation,  usually  those  done  for 
a  septic  condition  of  one  of  the  abdominal  viscera  or  a  diffuse  peritonitis, 
or  it  may  have  existed  before  operation.  It  is  characterized  by  per- 
sistent vomiting,  restlessness,  pain,  apprehension,  anxious  expression, 
abdominal  distention,  absent  peristalsis,  no  passage  of  fecal  matter  or 
flatus  and  later  by  a  complete  absence  of  pain,  but  unfortunately  by  a 
realization  of  danger  on  the  part  of  the  patient.  The  facial  expression 
is  that  topical  of  peritonitis  and  near  the  termination  the  patient  is  apt 
to  show  a  peculiarly  happy  form  of  deliriimi  in  which  he  may  convince 
the  inexperienced  that  he  is  much  better. 

Diagnosis. — It  is  not  always  easy  to  differentiate  this  type  from  the 
mechanical  and  the  difficulty  often  arises  because  we  have  present  both 
a  peritonitis  and  a  mechanical  obstruction.  The  t;\'pical  cases,  however, 
are  very  different  and  we  should  always  endeavor  to  distinguish  them, 
for  the  treatment  of  the  two  differs  greatly. 

Treatment. — In  the  mechanical  type,  unless  the  use  of  an  enema  or  the 
continuous  use  of  a  mild  remedy  such  as  mineral  oil  brings  complete 
relief,  operation  is  plainly  indicated  and  should  not  be  delayed.  Much 
valuable  time  is  lost  and  the  patient's  suffering  greatly  prolonged  and 
increased  by  the  use  of  purgatives  and  the  emploATuent  of  drugs  to 
increase  peristalsis.  ^Yhen  there  is  evidence  of  a  definite  obstruction 
one  should  operate  just  as  promptly  as  in  a  strangulated  hernia. 
Delay  means  gangrene  or  peritonitis  and  an  operation  which  may  be 
only  palliative  or  preliminary,  whereas  prompt  action  gives  extremely 
good  results  when  there  is  no  infection.  Before  re-opening  the 
abdomen  the  possibility  of  a  strangulated  hernia,  particularly  of  a 
partial  enterocele,  should  be  eliminated. 

The  choice  of  the  anesthetic  in  these  cases  is  of  great  importance  and, 
if  the  patient  has  been  vomiting  persistently,  gastric  lavage  should 
precede  the  anesthetic.  Whenever  the  patient  is  \'ery  ill  the  abdomen 
should  be  opened  under  infiltration  anesthesia  and  if  possible  the  entire 
operation  conducted  without  the  use  of  a  general  anesthetic.  As  a 
rule  the  previous  incision  can  be  re-opened,  but  if  this  is  so  placed  as  to 
give  poor  access  to  the  region  where  the  obstruction  is  suspected  or  is 
badly  placed  for  a  general  examination  of  the  abdominal  cavity,  a  new 
incision  should  be  made.  These  patients  can  usually  indicate  approxi- 
mately fairly  well  by  the  location  of  the  pain  and  tenderness  the  region 
in  which  the  obstruction  will  be  found.  After  the  abdomen  has  been 
opened  it  is  important  to  prevent  the  extensive  protrusion  of  the  coils 
of  distended  small  intestine.  Evisceration  for  the  purpose  of  locating 
the  point  of  obstruction  is  not  only  unnecessary  but  contra-indicated 
because  it  produces  shock,  increases  risk  of  infection  and  subjects  the 


COMPLICATIONS  AFTER  OPERATIONS  155 

distended  and  infected  bowel  to  unnecessary  traumatism.  The  site 
of  the  obstruction  can  usually  be  detected  by  tracing  the  distended 
bowel  until  the  collapsed  portion  is  encountered,  or  preferably  by 
tracing  the  collapsed  bowel  up  to  the  point  of  distention.  By  pursuing 
the  latter  plan  injury  to  the  distended  intestine  is  less  likely.  One 
should  not  feel  that  all  the  adhesions  encountered  should  be  separated, 
but  wherever  the  small  intestine  is  adherent  to  a  fixed  point,  such  as  the 
mesentery  or  the  abdominal  wall,  it  should  be  liberated.  If  the  patient's 
condition  is  very  bad,  it  may  be  a  better  plan  to  do  an  enterostomy, 
particularly  if  difficulty  is  encountered  in  finding  the  point  of  obstruc- 
tion. This  rule  should  certainly  be  followed  in  the  case  of  the  large 
intestine  as  it  is  a  well-established  rule  that  resections  of  the  large 
intestine  in  the  presence  of  acute  obstruction  are  contra-indicated. 
Resections  of  the  small  intestine  can  be  done  in  the  presence  of  acute 
obstruction  if  the  patient  is  not  very  ill  and  the  proxinial  portion  of  the 
bowel  is  in  good  condition.  The  short-circuiting  of  the  small  intestine 
by  anastomosing  a  coil  of  intestine  above  and  below  the  obstruction  is 
a  feasible  procedure  and  in  certain  instances  where  the  separation  of 
the  adhesions  may  mean  perforation  of  the  bowel,  a  wise  one. 

The  treatment  of  paralytic  ileus  due  to  peritonitis  is  the  same  as  that 
of  peritonitis,  which  has  been  fully  dealt  with  elsewhere.  The  majority 
of  surgeons  do  not  as  a  rule  recormnend  operative  interference  in  these 
cases  as  the  mortality  is  very  high  and  as  it  is  believed  that  practically 
as  many  cases  recover  without  as  with  operation.  Where  one  is  unable, 
however,  to  eliminate  the  question  of  mechanical  obstruction,  the 
abdomen  should  be  re-opened. 

I  believe  that  in  these  cases  the  best  results  will  be  obtained  by 
following  Ochsner's  method  of  treatment  in  general  peritonitis.  C.  L. 
Gibson  in  his  paper  already  referred  to  in  the  section  dealing  with 
paralytic  distention  expresses  great  confidence  in  the  use  of  pituitrin. 
In  the  septic  cases  I  have  had  but  little  experience  with  it  and  am  not 
in  a  position  to  recommend  or  decry  its  use. 

Acute  Dilatation  of  the  Stomach. — Acute  gastric  dilatation  or  gastro- 
mesenteric  ileus  may  occur  after  any  operation  but  is  most  frequently 
seen  after  abdominal  operations,  especially  those  involving  the  bile 
passages.  The  condition  is  also  seen  in  pneumonia  and  other  diseases 
which  are  in  no  sense  surgical.  The  explanations  of  the  condition  are 
so  numerous  and  diverse  that  it  may  be  safely  presumed  that  there  are 
many  causes  or  that  the  true  cause  is  unknown.  It  corresponds  in  many 
ways  to  the  paralytic  distention  of  the  small  intestine  already  described. 
Surgical  writers  have  laid  so  much  stress  upon  pressure  by  the  mesen- 
teric vessels  upon  the  duodenum  as  a  cause  that  the  term  gastro- 
mesenteric  ileus  has  become  synonymous  with  acute  dilatation  of  the 
stomach.  The  dilatation  has,  however,  in  too  many  cases  stopped 
short  of  the  mesentery  and  its  vessels  for  this  term  to  be  considered 
generally  applicable. 

In  septic  cases  the  condition  is  often  associated  with  general  dis- 
tention of  the  small  intestine  and  the  paresis  of  the  stomach  like  that 


156  POSTOPERATIVE   TREATMENT 

of  the  intestine  is  due  to  infection  but  it  is  seen  too  frequently  in  clean 
cases  and  where  no  operation  has  been  done  to  explain  all  cases  on 
this  basis.  The  following  paragraph  from  Crandon's  Surgical  After- 
treatment  gives  a  good  idea  of  the  variety  of  supposed  causes:  "It  is 
said  to  be  common  in  thin,  weakly  individuals,  especially  those  with 
general  enteroptosis.  Abdominal  tramna,  errors  of  diet,  the  accumula- 
tion of  gas  due  to  fermentation  of  retained  foods,  drinking  large  quan- 
tity of  fluids,  especially  carbonated  waters,  and  tight  abdominal 
binders  have  all  been  blamed  as  the  source  of  this  complication.  Con- 
nor makes  the  statement  that  obstruction  of  the  duodenum  by  the 
overlying  mesentery  must  be  regarded  as  a  factor  in  the  development  of 
one-third  to  one-half  of  all  cases  of  acute  gastrectasis,  and  Polak  states 
there  can  be  no  doubt  but  that  the  Fowler  posture  favors  constriction  of 
the  lower  end  of  the  duodenum  between  the  root  of  the  mesentery  and 
the  vertebral  column.   Peritonitis  may  be  a  factor  in  certain  cases." 

Bloodgood^  discusses  the  subject  at  length  and  considers  mesenteric 
pressure  at  the  juncture  of  duodenum  and  jejunum  the  commonest 
cause  and  reports  several  cases. 

Chloroform  anesthesia  and  pyloric  spasm  are  two  other  causes  which 
have  been  suggested. 

The  whole  subject  has  been  exhaustively  dealt  with  by  Lewis  A. 
Connor-  of  New  York,  and  later  by  Laffer^  who  has  collected  217  cases 
and  gives  an  extensive  bibliography. 

Vomiting  is  the  most  conmion  and  pronounced  symptom  although  it 
has  been  absent  in  a  few  cases.  The  profuseness  of  the  vomiting  is 
distinctive  and  has  usually  been  persistent,  although  intermittence 
has  been  noted  and  the  vomiting  is  apt  to  cease  some  hours  before 
death.  The  fluid  vomited  is  bile-stained  and  has  a  sweetish  odor.  It 
is  never  fecal. 

The  distention  is  characteristic  in  the  t^'pical  case,  it  is  first  noticed 
in  the  epigastrium  and  extends  then  to  the  left  side.  In  the  early  stages 
the  lower  abdomen  remains  flat  or  even  scaphoid,  though  the  stomach 
has  in  one  or  two  instances  been  so  dilated  as  to  flll  the  entire  abdomen. 
The  succussion  splash  can  usually  be  detected.  Pain  or  a  sense  of 
great  discomfort  in  the  epigastrimn  is  a  more  or  less  constant  symptom. 
The  facial  expression  denotes  distress  and  anxiety  and  hiccough  is  often 
present.  Constipation  is  the  rule  but  in  a  few  cases  there  has  been  a 
marked  diarrhea.  A  visible  peristaltic  wave  has  been  noted  by  Blood- 
good  and  others  but  it  has  not  been  a  common  sign.  The  pulse-rate 
increases  with  the  distention  but  the  temperature  remains  normal  or 
subnormal.  Respiration  is  rapid  and  embarrassed  and  dyspnea  may 
develop.  Nearly  all  observers  have  referred  to  the  complaint  of  great 
thirst.  Collapse  may  supervene  in  twenty-four  or  forty-eight  hours 
after  the  onset  of  dilatation,  but  many  cases  have  extended  over  a 
number  of  days  and  relapses  are  reported  even  after  an  apparent  com- 
plete recovery. 

'  Ann.  Surg.,  1907,  xlvi,  736. 

2  Am.  Jour.  Med.  Sc,  1907,  cxxxiii,  345.  '  Loc.  cit. 


COMPLICATIONS  AFTER  OPERATIONS  157 

Prognosis. — ^The  prognosis  is  very  grave  in  this  condition.  Laffer 
gives  the  mortality  in  his  collection  of  217  cases  as  63.5  per  cent.  A 
study  of  the  reported  cases  goes  to  show  that  the  mortality  is  influenced 
very  largely  by  the  promptness  with  which  the  condition  is  recognized 
and  the  persistence  with  which  the  stomach  tube  is  employed. 

Treatment. — As  might  be  expected  from  a  consideration  of  the  many 
causes  of  the  condition,  the  treatment  is  more  or  less  unsettled.  The 
repeated  employment  of  gastric  lavage  regardless  of  the  seriousness 
of  the  patient's  condition  and  continuous  enteroclysis  constitute  the 
most  valuable  means  we  have  of  relieving  the  condition.  Great  stress 
has  been  laid  by  a  number  of  WTiters  upon  the  importance  of  keeping 
the  patient  either  in  the  prone  position  or  on  his  right  side  and  many 
recoveries  have  been  attributed  to  the  avoidance  of  the  dorsal  position. 
It  seems  hardly  necessary  to  state  that  nothing  whatever  in  the  way 
of  food,  drugs  or  drinks  should  be  given  by  the  mouth.  Although 
various  operative  procedures  have  been  undertaken  for  the  relief  of 
acute  dilatation,  gastro-enterostomy  is  the  only  one  which  would 
seem  feasible  but  even  after  its  performance  the  repeated  use  of  the 
stomach  tube  may  be  necessary  as  the  new  stoma  does  not  always 
drain  the  stomach.  In  fact  one  case  has  been  reported  where  fatal 
dilatation  followed  gastrojejunostomy  and  at  the  autopsy  the  new 
opening  as  well  as  the  pylorus  showed  no  obstruction. 

I  am  inclined  to  believe  that  a  successful  treatment  of  these  cases 
depends  upon  the  early  recognition  of  the  condition  and  the  prompt 
and  repeated  use  of  the  stomach  tube. 

Hiccough. — Hiccough  often  becomes  a  distressing  postoperative 
complication  but  it  cannot  in  any  sense  be  attributed  to  the  operation 
in  most  cases.  This  spasm  of  the  diaphragm  is  reflex  and  is  due  to 
irritation  of  the  pneumogastric  or  phrenic  nerves.  It  is  seen  usually 
where  there  is  an  inflammation  in  the  structures  supplied  by  the  nerves, 
but  it  often  occurs  where  no  such  condition  can  be  demonstrated  dm"ing 
life  or  at  autopsy,  for  occasionally  it  alone  is  responsible  for  death. 
The  surgeon  sees  it  usually  in  cases  of  peritonitis  and  after  operations 
on  the  upper  abdomen.  I  have  seen  persistent  hiccough  follow  two 
cases  of  gunshot  wound  involving  the  diaphragm;  both  patients 
recovered. 

Treatment.^ — Xo  reliable  method  of  treatment  can  be  given.  It  is 
well  first  to  eliminate  any  discernible  cause  of  irritation  in  the  gastro- 
intestinal and  respiratory  tracts  which  may  possibly  cause  the  con- 
dition. Such  simple  means  as  holding  the  breath  and  drinking  water 
or  semifluids,  which  are  efficacious  when  hiccough  occurs  in  health, 
may  be  employed  first  and  later  compression  of  the  loAver  thorax  and 
abdomen  by  a  tight  bandage  or  the  hands.  Antispasmodic  medicines 
may  also  be  employed  and  I  think  it  is  important  to  see  that  the  patient 
gets  either  by  the  mouth  or  rectum  large  quantities  of  water. 

Acidosis. — This  question  has  become  one  of  practical  importance 
to  the  surgeon  in  estimating  the  risks  of  operation  and  in  the  pre-  and 
postoperative  treatment. 


158  POSTOPERATIVE   TREATMENT 

Acidosis,  acetonuria  or  acidemia  first  engaged  surgical  attention 
when  it  was  shown  to  follow  the  administration  of  a  general  anesthetic, 
especially  chloroform  and  particularly  in  children.  The  "late  chloro- 
form poisoning"  which  has  long  been  recognized  and  variously  explained 
is  acidosis.  Ten  years  ago  the  surgical  literature  teemed  with  reports 
of  postanesthetic  deaths  due  to  acetonuria  and  postoperative  diabetic 
coma.  An  enormous  advance  has  been  made  in  our  knowledge  of  this 
important  subject  by  the  work  done  in  the  laboratories  of  physiological 
chemistry  and  experimental  surgery.  Crile  has  probably  done  more 
than  anyone  else  in  this  country  to  i)ut  this  matter  before  the  surgical 
profession  and  his  laboratory  and  experimental  work  has  the  advantage 
of  being  supported  by  a  large  clinical  experience. 

It  is  probably  safe  to  say  that  a  certain  degree  of  acidosis  exists  for 
a  limited  period  of  time  after  any  surgical  operation  which  necessitates 
a  general  anesthetic  (of  whatever  kind),  produces  pain,  or  occupies 
any  length  of  time,  and  is  manifested  by  rapid  respiration,  sweating, 
late  or  persistent  vomiting,  the  odor  of  acetone  on  the  breath,  increase 
in  pulse-rate,  great  thirst,  and  the  presence  of  acetone  and  acid  bodies 
in  the  urine.  In  the  more  marked  cases  which  we  designate  as  toxemia, 
the  s^Tnptoms  are  persistent,  very  much  increased  and  the  patient  is 
apt  to  pass  into  a  coma  and  die. 

Anesthetics  and  surgical  operations  are  not  the  only  causes  of 
decreased  alkalinity  of  the  blood,  for  Crile  and  others  have  shown  that 
exertion,  emotion,  injury,  infection,  auto-intoxication.  Graves'  disease, 
etc.,  may  cause  it.  He^  says  of  his  studies  of  this  subject  that  "they 
determine  that  the  brain,  the  adrenals,  the  liver,  the  thyroid,  and  the 
muscles  together  play  important  parts  in  energy  transformation,  and 
that  at  least  three  of  these  organs,  the  brain,  the  adrenals,  and  the 
liver,  are  especially  concerned  also  in  the  neutralization  of  the  acids 
resulting  from  energy  transformation,"  and  again  "if  in  a  certain  case 
there  is  shown  a  continuous  increase  of  acid  by-products  for  the 
neutralization  of  which  an  unusual  amount  of  alkali  is  required,  then 
w^e  may  presume  the  liver,  the  adrenals,  and  the  brain  are  undergoing 
abnormal  changes;  and  that  unless  the  acid  condition  be  altered,  these 
structural  changes  in  the  brain,  the  adrenals,  and  the  liver  will  become 
permanent  and  certain  of  the  chronic  diseases  will  result." 

That  all  general  anesthetics  produce  acidosis  is  also  testified  to  by 
Crile  who  says  that  "nitrous  oxid,  ether  and  chloroform  during  their 
administration  all  produce  increased  acidity  of  the  blood.  In  our 
experiments  we  have  found  out  recently  the  additional  fact  that  the 
acidity  of  the  urine  is  increased  markedly  under  ether  and  chloroform 
and  less  under  nitrous  oxid.  This  finffuig  has  a  most  Important  signifi- 
cance for  the  surgeon,  as  it  explains  why  the  administration  of  the 
anesthetic  to  a  starved  patient  with  gastric  or  duodenal  ulcer,  for 
example,  may  cause  death  by  precipitating  the  impending  acidosis." 
I  might  add  that  chloride  of  ethyl  which  I  have  used  extensively  during 
the  past  fifteen  years  is  no  exception  to  the  rule. 

1  Tr.  Am.  Surg.  Assn.,  1915. 


COMPLICATIONS  AFTER  OPERATIONS  159 

With  these  evidences  of  the  cause  or  causes  of  this  common  post- 
operative condition,  we  should  pay  some  attention  to  the  subject  in 
preparing  our  cases  for  operation  and  in  endeavoring  to  prevent  or 
limit  the  postoperative  acidosis. 

First  we  should  do  ever}i;hing  to  eliminate  fear,  avoid  starvation, 
give  plenty  of  water,  traumatize  tissue  as  little  as  possible,  make  our 
anesthesias  as  short  as  possible  consistent  with  thorough  surgery,  and 
exercise  a  choice  of  anesthetics. 

The  treatment  of  acidosis  can  be  expressed  in  two  words :  water  and 
alkalis;  the  one  hastening  elimination  of  the  acids  and  the  other 
neutralizing  them.  Soda  bicarbonate  is  the  simplest  and  best  alkali 
aiid  can  be  given  by  the  mouth  when  vomiting  is  not  marked  and  the 
symptoms  not  severe.  Twenty  or  thirty  grains  should  be  given  every 
hour  or  two.  Subcutaneous  administration  may  produce  irritation 
and  abscesses.  In  most  cases  the  rectum  is  the  best  avenue  for  this 
medication  which  should  be  given  by  the  continuous  "^lurphy  drip" 
method.  Three  or  four  hundred  grains  a  day  is  not  too  much.  Carbo- 
hydrates are  also  indicated  in  the  postoperative  treatment  of  this 
condition. 

In  all  cases  after  a  prolonged  anesthesia,  in  severe  shock  after  the 
loss  of  considerable  blood  and  whenever  an  acidosis  might  naturally 
be  expected,  bicarbonate  of  soda  and  large  quantities  of  water  should 
be  given  by  continuous  enteroclysis. 

Thrombophlebitis — Pulmonary  Embolism. — Thrombophlebitis  is  a 
fairly  common  postoperative  complication,  especially  after  operations 
upon  the  female  pelvic  viscera  and  rectum.  It  is  also  seen  occasionally 
after  operations  for  hernia  and  appendicitis.  Anemia  particularly 
favors  this  complication  and  consequently  it  is  seen  more  frequently 
after  operations  for  fibroid  tumors  which  have  caused  profuse  bleeding. 
General  debility  of  the  patient  also  predisposes  to  the  condition. 

As  a  rule  thrombophlebitis  does  not  occur  until  about  ten  days  have 
elapsed  after  the  operation  and  often  not  until  the  patient  gets  out  of 
bed. 

The  veins  most  frequently  involved  are  the  pelvic  tributaries  of  the 
iliac,  the  long  saphenous,  especially  the  left,  and  the  femoral.  The  con- 
dition is  not  in  itself  serious  and  recovery  as  a  rule  is  complete  but  there 
is  always  the  possibility  of  the  detachment  of  an  embolus  -with  its  sub- 
sequent lodgment  in  the  pulmonary  circulation.  A  less  serious  and  more 
frequent  result  of  thrombophlebitis  is  varicose  veins.  The  frequency 
of  the  condition  in  the  pelvic  veins  is  indicated  by  the  casual  finding  of 
phleboliths  in  a--ray  plates  of  the  pelvis.  These  phleboliths  represent 
the  calcification  of  a  thrombus.  Although  permanent  occlusion  of  the 
vein  by  the  clot  and  conversion  into  a  fibrous  cord  is  a  common  result 
of  thrombophlebitis,  in  many  cases  complete  blocking  of  the  vein  does 
not  occur  and  the  normal  caliber  is  reestablished  through  absorption 
and  repair. 

The  cause  of  thrombophlebitis  has  been  a  matter  of  much  discussion. 
]\Iost  authors,  however,  agree  that  infection  is  the  most  common 


160  POSTOPERATIVE   TREATMENT 

factor.  Da  Costa^  says  "  In  the  formation  of  thrombi  four  conditions 
are  to  be  considered,  viz.,  chemical  alterations  in  the  blood,  a  bacterial 
attack  on  the  intima,  tissue  changes  in  the  inner  coat  of  the  vessel,  and 
slowing  of  the  circulation.  .  .  .  The  essential  cause  of  all  intra- 
vascular thrombi  is  damage  to  the  endothelial  coat  and  in  most 
instances  the  damage  is  effected  by  bacteria,  hence  most  cases  of 
thrombosis  seen  by  the  surgeon  are  infectious." 

It  cannot  be  denied,  however,  that  thrombosis  frequently  occurs 
in  patients  who  show  no  evidence  whatever  of  any  septic  process. 

Of  the  symptoms  pain,  tenderness  and  edema  are  the  most  con- 
spicuous. When  the  leg  is  involved  the  patient  usually  complains  of 
pain  in  the  calf  and  over  the  long  saphenous  and  pressure  in  these 
regions  reveals  great  tenderness  and  in  a  short  time  the  leg  becomes 
edematous.  There  is  a  moderate  rise  in  temperature  and  a  consider- 
able increase  in  the  pulse-rate.  In  the  septic  cases  the  symptoms  are 
often  preceded  by  a  slight  chill  or  chilly  sensations. 

In  the  case  of  the  pelvic  veins,  vaginal  or  rectal  examination  reveals 
tenderness  and  edema  and  if  the  iliac  or  femoral  veins  become  subse- 
quently involved  edema  of  the  extremity  occurs.  Extension  of  the 
process  from  one  extremity  to  the  other  is  by  no  means  infrequent, 
there  usually  being  an  interval  of  several  days  between  the  two  involve- 
ments. With  complete  thrombosis  of  the  superficial  veins  one  is  able 
to  palpate  them  easily  and  the  tributary  veins  are  often  markedly 
distended. 

Under  proper  treatment  the  acute  symptoms  subside  in  a  few  days 
but  the  swelling  may  not  disappear  for  two  or  three  weeks.  If  the 
patient  is  allowed  to  get  out  of  bed  before  the  condition  has  entirely 
subsided  there  is  a  rapid  recurrence  of  the  edema. 

The  treatment  consists  in  absolute  rest  in  bed  with  moderate 
elevation  of  the  part  and  the  application  of  an  ice-bag.  Many  surgeons 
prefer  to  apply  heat  but  I  have  certainly  had  more  satisfaction  in  the 
use  of  the  ice-bag.  An  absorbent  ointment  of  belladonna  and  ichthyol 
seems  also  to  give  comfort,  especially  where  the  superficial  veins  are 
acutely  inflamed,  as  indicated  by  a  redness  of  the  overlying  skin.  The 
patient  should  not  be  allowed  to  become  constipated  but  the  bowels 
should  be  kept  open  by  either  mild  laxatives  or  the  use  of  enemata. 
Massage  of  even  the  lightest  character,  which  the  patient  often  asks 
for,  should  never  be  permitted  because  of  the  likelihood  of  detaching  a 
portion  of  the  clot.  The  patient  should  be  kept  in  bed  for  at  least  ten 
days  after  the  subsidance  of  all  symptoms.  Many  cases  of  fatal  pul- 
monary embolism  have  occurred  on  the  day  the  patient  first  gets  out 
of  bed. 

It  has  been  suggested  by  many  surgeons  that  ligation  or  ligation  and 
extirpation  of  thrombosed  veins  should  be  done  in  order  to  prevent 
the  serious  complication  of  pulmonary  embolism.  Although  such  pro- 
cedures might  prevent  a  catastrophe  in  rare  instances,  its  use  in  all 
cases  would  certainly  seem  to  be  unjustifiable. 

1  Modern  Surgery,  7th  edition,  p.  185. 


COMPLICATIONS  AFTER  OPERATIONS  161 

Pulmonary  Embolism. — Pulmonary  embolism  is  caused  by  the  dis- 
lodgment  of  a  clot  or  portion  of  a  clot  which  is  blocking  one  of  the 
veins  and  which  finally  lodges  in  one  of  the  bifurcations  of  the  pul- 
monary artery.  If  the  clot  is  a  small  one  it  may  not  lodge  until  it 
reaches  the  smaller  branches  of  the  pulmonary  and,  if  no  large  clot 
forms  behind  it,  the  portion  of  the  lung  supplied  by  the  branch  becomes 
ischemic  and  an  infarct  develops.  If  such  a  small  clot  is  septic,  a  septic 
pneumonia  results.  If  the  larger  branches  of  the  pulmonary  artery  are 
blocked  by  the  embolus  a  rapid  clot  forms  behind  it  and  the  patient 
will  die  within  a  few  minutes  or  within  a  few  hours.  Lodgment  of  small 
emboli  in  the  pulmonary  circulation  is  probably  more  frequent  than 
is  generally  supposed  and  often  is  not  recognized,  although  the  physical 
signs  are  usually  distinct  after  a  day  or  two.  The  serious  type  of  pul- 
monary embolism  is  by  no  means  rare  and  is  a  common  cause  of  sudden 
death  after  operation.  Such  a  catastrophe  may  take  place  a  day  or  two 
after  the  operation  or  may  not  occur  for  several  weeks  as  it  usually 
follows  a  recognized  thrombophlebitis.  It  frequently  occurs  after 
abdominal  operations,  however,  where  there  has  been  no  evidence  of 
thrombophlebitis.  It  is  probably  the  most  rapidly  fatal  and  most 
distressing  postoperative  complication. 

Symptoms. — ^The  symptoms  are  unmistakable,  the  patient  being 
suddenly  seized  with  a  sense  of  suffocation  or  pain  in  the  chest  with 
rapidly  failing  circulation  and  marked  dyspnea.  Anxiety,  apprehen- 
sion and  restlessness  together  with  a  sense  of  impending  death  are 
present.  In  practically  all  cases  these  symptoms  are  rapidly  followed 
by  dilatation  of  the  pupils,  cold  sweat  and  unconsciousness.  The 
patient  may  die  in  less  than  a  minute  or  may  survive  for  several  hours. 

Treatment. — ^The  treatment  is  most  unsatisfactory  and  consists  in 
the  administration  by  hypodermic  of  cardiac  and  respiratory  stimu- 
lants, particularly  camphor  and  ether,  in  the  employment  of  artificial 
respiration,  and  in  the  use  of  morphin  and  atropin. 

Wherever  a  thrombophlebitis  is  present  one  cannot  be  too  careful 
in  seeing  that  the  patient  avoids  any  strenuous  movement  or  straining 
and  that  he  does  not  get  out  of  bed  for  ten  days  or  two  weeks  after  all 
symptoms  have  subsided.  This  care  will  be  appreciated  when  it  is 
remembered  that  the  catastrophe  has  occurred  in  many  patients  when 
they  have  first  sat  up  in  bed  or  on  their  first  day  out  of  bed. 

The  operative  treatment  of  this  condition  remains  sub  judice. 
Trendelenburg  was  the  first  to  suggest  and  practice  the  removal  of  the 
clot  from  the  pulmonary  artery  and  has  performed  the  operation 
several  times.  In  none  of  the  cases  has  it  been  successful  although  two 
of  the  patients  have  survived  the  operation.  The  pulmonary  artery 
is  exposed  by  resecting  the  second  rib  and  opening  the  pleura  and  peri- 
cardium; it  is  then  incised,  the  clot  extracted  and  the  wound  closed. 
In  order  to  successfully  accomplish  the  operation  it  should  be  carried 
out  with  the  greatest  promptness  and  celerity.  I  know  of  no  complete 
recovery  following  this  operation  and  the  only  warrant  for  its  per- 
formance is  the  universally  fatal  result  which  follows  the  occlusion  of 
the  pulmonary  artery  by  a  clot. 

VOL.  I. — 11 


VACCINES. 

By  a.  F.  JONAS,  M.D. 

GENERAL   STATEMENT. 

We  must  guard  against  the  optimism  of  certain  enthusiasts  in 
vaccine  therapy  who  look  upon  every  recovery  from  an  infection,  as 
being  brought  about  by  vaccine  which  they  may  have  administered. 
The  experienced  practitioner  who  had  become  famihar  with  infections 
long  before  the  advent  of  vaccines,  has  been  among  the  first  to  note 
that  the  majority  of  infections  are  self-Hmited  and  end  in  recovery 
quite  as  promptly  as  those  cases  in  which  the  vaccine  therapy  has 
been  used.  Therefore,  many  of  the  claims  made  for  the  advanced 
therapy  are  not  borne  out  by  every-day  experience.  But  to  dis- 
credit the  entire  method,  as  is  done  by  some,  is  not  warranted.  That  the 
underlying  principles  appear  to  be  well  founded,  but  there  is  something 
wrong  with  the  method,  is  well  expressed  by  Hektoen.  He  states: 
"The  simple  fact  is  that  we  have  no  reliable  evidence  to  show  that 
vaccines,  as  used  commonly,  have  the  uniformly  prompt  and  specific 
CLirative  effects  proclaimed  by  optimistic  enthusiasts,  and  especially 
by  certain  vaccine  makers  who,  manifestly,  have  not  been  safe  guides 
to  the  principles  of  successful  and  rational  therapeutics." 

We  know  from  everyday  experience  that  if  we  carefully  search 
for  the  source  of  the  infection  and  relieve  the  primary  focus  by  local 
treatment,  as  for  example,  a  thorough  disinfection  at  the  port  of 
entry,  the  free  evacuation  of  localized  infectious  material  in  the  form 
of  pus  or  any  foreign  substance  facihtating  free  drainage,  the  absorp- 
tion of  toxins  will  cease  and  bacterial  propagation  will  come  to  an 
end  without  further  systemic  treatment.  The  normal  immunization 
mechanism  will  rapidly  eliminate  and  bring  to  an  end  bacterial 
propagation  and  their  products. 

Wright  made  a  determined  effort  to  place  vaccine  therapy  on  an 
exact  basis.  His  discovery  of  opsonins  and  the  use  of  the  opsonic 
index  as  a  guide  to  the  administration  of  vaccines  was  an  encourag- 
ing move  in  the  right  direction  and  was  at  first  generally  accepted  by 
the  profession.  The  painstaking  and  exact  microscopic  training  and 
laboratory  equipment  that  the  method  required  was  found  to  be 
impractical  for  the  general  practitioner,  and  it  soon  fell  into  disfavor. 
Further,  laboratory  experts  questioned  the  accuracy  of  the  method 
and  it  was  not  regarded  as  essential  by  many  practical  workers. 
Very  soon  stock  vaccines  came  into  general  use.  Their  effects 
appeared  doubtful  and  the  whole  method  became  discredited.     How- 

( 163 ) 


164  VACCINES 

ever,  enough  of  the  principles  of  their  action  was  known  to  be  well 
founded  in  that  certain  investigators  pointed  to  the  fact  that  a  vac- 
cine should  be  made  from  microorganisms  taken  from  the  individual 
sufi'ering  from  the  disease,  and  they  insisted  on  autovaccines.  The 
preparation  of  auto^'accines,  however,  must  ever  be  regarded  in  the 
majority  of  infections  as  the  only  exact  and  scientific  method  in  the 
use  of  vaccines.  When  we  pursue  the  reports  of  Rosenau  wherein 
he  shows  the  frequent  and  almost  constant  change  in  the  strains  of 
bacterial  growth,  we  are  impressed  with  the  necessity,  if  vaccines 
are  at  all  useful,  of  making  vaccines  from  the  blood  or  pathogenic 
products  of  each  individual  who  is  being  treated.  Xo  two  individuals 
are  affected  by  or  react  to  a  given  bacterial  toxin  in  precisely  the 
same  way. 

It  is  clear  that  each  individual  harbors  microorganisms  that  are 
specific  to  himself,  and  must  differ  from  those  of  every  other  indi- 
vidual. Therefore,  to  obtain  the  best  possible  results,  each  individual 
must  furnish  his  own  vaccines.  But  to  do  this  is  clearly  beyond 
the  general  practitioner  and  most  hospital  attendants.  When  this 
fact  was  realized,  especially  in  our  country,  it  was  not  long  before 
there  was  an  unrestrained  and  indiscriminate  exploitation  of  vaccines 
by  certain  makers.  The  profession  was  easily  persuaded  to  employ 
the  many  products  put  out  by  commercial  firms.  Autovaccines 
rapidly  gave  way  to  stock  vaccines.  The  commendable  efforts  to 
secure  exactness  soon  were  displaced  by  routine  and  guesswork. 
Commercial  concerns  became  the  educators  in  vaccine  therapy. 
The  fundamental  principle  that  vaccines  must  contain  bacteria  that 
are  exactly  or  nearly  identical  with  the  strains  causing  the  infection 
was  forgotten.  It  is  clear  that  with  vaccines  made  in  large  quantities, 
this  condition  cannot  be  maintained.  "The  changes  in  virulence  and 
affinities  which  take  place  in  bacteria  under  artificial  cultivation 
cannot  be  avoided."  (Hektoen.)  It  cannot  be  expected  that  the 
specific  element  on  which  the  desired  antigenic  effect  depends  is  still 
existent. 

The  wholesale  producer  of  vaccine  soon  evolved  a  shotgun  vaccine 
which  he  termed  a  polyvalent  vaccine,  which  contained  all  manner 
of  strains  of  nearly  the  whole  group  of  pathogenic  bacteria.  But,  after 
all,  like  the  shotgun  prescription  of  old  containing  many  drugs,  this 
is  a  poor  substitute  for  a  specific  autogenous  vaccine.  The  use  of  an 
autovaccine  means  a  careful  study  of  the  case  under  treatment.  It 
means  an  exact  diagnosis.  If  it  is  true  that  every  microorganism 
produces  its  own  antibody,  an  etiological  diagnosis  is  imperative. 
It  is  owing  to  this  last  essential  that  the  autovaccine  therapy  has 
been  robbed  of  its  practicability.  Because  physicians  are  either  not 
equipped  or  not  trained  and  also  lack  the  time  to  make  an  etiological 
diagnosis,  the  mixed  unstandardizable  vaccines — phylacogens — have 
enjoyed  more  or  less  popularity.  These  preparations  have  no  anti- 
genic value  and  are,  at  best,  only  poor  uncontrollable  makeshifts. 
The  tendency  of  the  medical  attendant  is  to  become  more  superficial 


GENERAL  STATEMENT  165 

in  the  examination  of  his  patient  and  subsequently  his  diagnosis  is 
more  inexact. 

The  tendency  to  the  emplo}Tnent  of  vaccines  in  all  forms  of  infec- 
tions, both  acute  and  chronic,  the  vast  majority  of  which  are  self- 
limited,  is  to  be  deplored.  This  practice  has  given  rise  to  undeserved 
praise  of  many  vaccines  that  really  are  inert  and  ineffective  and  leads 
to  erroneous  conclusions.  Its  tendency  is  to  discredit  the  entire 
vaccine  therapy  in  the  minds  of  many  observers. 

While  we  have  met  with  many  disappointments,  we  must  ascribe 
the  failures  to  the  methods  of  their  employment.  Vaccine  therapy  is 
of  undoubted  value  as  has  been  shown  by  its  emplo^Tuent  in 
tj^phoid  by  Fraenkel,  Ichikawa  and  in  pneumonia  by  Rosenow  and 
others.  And  more  recently  as  prophylactic  in  tetanus,  especialh'  in 
the  late  European  war.  The  method  is  of  undoubted  value  and 
has  found  a  permanent  place  in  our  armamentarium  in  the  treatment 
of  certain  infections.  At  present,  the  main  facts  are  obscured  by  a 
mass  of  uncertain  and  ill-considered  theories  and  fault}'  application. 
But  we  are  in  possession  of  sufficient  facts  that  will  enable  us  to 
make  intelligent  use  of  vaccines  in  certain  well-selected  cases.  ^Yhile 
we  may  accept  the  teaching  that  all  vaccines  should  be  made  from  the 
microoorganism  causing  the  disease  in  each  individual,  which  is 
especially  true  in  acute  cases,  we  cannot  condemn  all  stock  vaccines. 
Occasionally  the  use  of  the  latter  has  been  followed  by  prompt  results. 
In  the  absence  of  time  and  a  proper  equipment  for  the  production  of 
autovaccines,  stock  vaccines  may  be  resorted  to  providing  an  exact 
diagnosis,  either  clinical  or  bacteriological  or  both,  can  be  made. 

We  must  not  lose  sight  of  the  fact  that  within  the  human  organism, 
there  exists  a  self-immunizing  power  that  is  responsible  for  spontaneous 
recovery  from  bacterial  disease.  There  is  a  cellular  mechanism  that 
exerts  a  destructive  effect  on  bacteria. 

The  human  organism  is  constantly  exposed  to  the  inroads  of  bacteria 
of  various  kinds.  As  long  as  the  immunizing  or  protective  mechanism 
■can  cope  successfully  with  the  invading  organism  so  long  we  have 
health;  if  the  protective  mechanism  fails  and  the  microorganisms  are 
not  inhibited,  we  have  disease. 

Artificial  stimuli  may  so  affect  the  immunizing  processes  that 
individuals  may  become  immune  to  a  certain  disease  by  inoculation 
with  specific  antitoxins.  Persons  may  be  made  immune  to  smallpox, 
typhoid,  rabies,  diphtheria  and  other  diseases  by  the  use  of  artificially 
prepared  vaccines  and  serums  that  contain  antibodies  which  are 
specifically  antagonistic  to  organisms  found  in  each  disease. 

The  animal  organism  adapts  itseff  to  various  noxious  conditions 
by  a  gradual  process  of  elaborating  bodies  antagonistic  to  them. 

While  stud}dng  the  process  of  immunization  and  particularly  the 
ways  of  increasing  the  power  of  the  immunizing  mechanism,  we  must 
not  forget  that  there  are  several  processes,  besides  vaccines,  that 
play  an  important  role.  The  removal  of  foreign  bodies,  elimination 
of  infectious  material  by  drainage,  germicides  or  antiseptics,  cellular 


166  VACCINES 

infiltration  and  the  flow  of  blood  to  the  seat  of  infection  known  as 
active  and  passive  hyperemia  which  may  be  increased  by  massage 
suction,  antitoxins,  vaccines  and  bacteriotropic  chemicals,  all  of 
these  may  be  aided  by  hygienic  measures. 

Animal  experiments  have  proved  that  gradually  increasing  doses  of 
a  given  poisonous  substance,  by  a  process  of  adaptation  of  the  immun- 
izing mechanism,  will  enable  the  animal  finally  to  tolerate  amounts 
that  would  have  proved  fatal  if  given  as  an  initial  dose. 

When  recovery  from  an  infection  takes  place,  we  assume  that 
the  immunizing  mechanism  is  producing  an  antitoxin  of  sufficient 
power  to  neutralize  the  toxin  that  circulates  in  the  body  fluids.  If  we 
inject  an  artificial  antitoxin,  we  add  to  the  already  existing  anti- 
toxins and  in  that  way  relieve  the  excessive  strain  put  on  the  body 
cells. 

There  are  other  substances  aside  from  toxins  that  protect  the  body. 
There  are  a  number  of  substances  classed  under  the  head  of  antitropin 
that  play  their  role  in  the  protective  process.  We  find  that  they  exert 
their  power  against  microorganisms,  each  in  its  own  way.  We  find 
that  such  organisms,  as  found  in  t\q3hoid  and  other  diseases,  when 
killed  and  then  injected  into  the  body  already  infected  with  the  same 
organism,  have  acquired  the  power  of  agglutinating  and  liquifying  these 
organisms  and  destroying  them.  We  speak  of  these  substances  as 
agglutinins,  bactericidins  and  bacteriolysins.  The  role  of  these  anti- 
bacterial bodies  is  an  important  one  in  the  control  of  many  infectious 
diseases. 

There  is  another  factor  aside  from  antibacterial  substances  known 
as  opsonins  that  seem  to  bear  a  close  relation  to  leukocytes  and  phago- 
cytic cells.  The  opsonins  seem  to  prepare  the  bacteria  so  that  they 
are  more  easily  taken  up  by  the  phagocytes  and  destroyed.  There- 
fore, w^e  find  that  the  antitropin,  the  opsonins  and  the  phagocytes 
have  a  destructive  effect  on  all  forms  of  pathogenic  bacteria. 

In  the  light  of  our  present  knowledge,  we  may  assume  that  phago- 
cytosis and  opsonins  are  the  chief  factors  in  establishing  the  line  of 
first  defense  against  invading  bacteria. 

According  to  Wright,  opsonins  probably  develop  from  the  con- 
nective-tissue cells,  and  are  produced  by  a  stimulation  of  specific 
poisons  forming  protective  substances.  These  protective  substances 
may  be  regarded  as  free  receptors  which  destroy  bacteria.  Opsonins 
and  other  antibacterial  substances  are  formed  by  an  inoculation  of 
killed  cultures  of  vaccines.  New  substances  are  formed  which  play 
their  role  in  the  disintegration  of  bacteria;  these  new  substances  are 
known  as  antibodies,  bactericidins,  agglutinins  and  opsonins,  they 
are  taken  up  in  the  blood  stream  and  find  their  way  to  all  parts  of  the 
body  and  to  the  foci  of  infection  and  unite  with  the  bacteria  causing 
their  destruction. 

When  bacteria  enter  the  subcutaneous  or  submucous  connective 
tissues  they  encounter  the  first  activie  defenses  in  the  form  of  opsonins 
and   phagocytic  cells.     The   fact   that    general    systemic    infections 


GENERAL  STATEMENT  167 

must  be  frequent,  suggest  that  the  body  possesses  defenses  greater 
than  can  be  furnished  by  the  usual  opsonins  and  phygocytic  cells  at 
the  point  of  infection.  We  find  that  the  usual  defenses  are  enhanced 
by  an  active  hyperemia,  a  reaction  known  as  inflammation.  The 
increased  blood  flow  carries  an  increased  amount  of  antibacterial 
bodies  and  fresh  leukocytes.  This  process  is  prompt  and  efficient  in 
the  innumerable  instances  where  bacteria  penetrate  the  connective 
tissue.  Should  this  united  phenomenon  of  active  hyperemia  fail, 
the  first  defenses  would  yield,  then  infectious  diseases  would  develop. 
If  the  virulence  of  the  invading  bacteria  is  of  such  a  great  degree  or 
their  numbers  are  greater  than  the  active  hyperemia  is  capable  of 
controlling,  the  defenses  are  defective.  All  observations  tend  to  con- 
firm the  accepted  facts  that  the  reaction  developing  immediately  after 
the  entrance  of  an  infection  known  as  inflammation,  is  essentially  a 
protective  process  in  all  its  phases. 

Of  recent  years,  a  method  of  prophylaxis  and  the  treatment  of 
certain  diseases  with  vaccines  has  become  popular  and  has  been 
practised  with  more  or  less  success.  This  method  consists  of  the  use 
of  certain  agents  that  have  become  known  as  vaccines.  The  term 
vaccine  is  derived  from  the  Latin  word  vacca  (a  cow)  and  refers  to  the 
"cow  disease"  or  cowpox  and  has  been  called  vaccinia.  Jenner 
described  his  discovery  as  a  protective  inoculation  against  smallpox 
with  cowpox  virus  and  termed  the  method  vaccination.  The  terms 
vaccine  and  vaccination  do  not  accurately  describe  the  material  used 
in  treatment  of  all  infectious  diseases.  Jenner,  being  acquainted  with 
only  one  form  of  disease  and  its  treatment,  naturally  applied  the  term 
suitable  to  his  epoch-making  method.  Perhaps  out  of  respect  for 
the  great  Englishman,  later  investigators,  chief  among  whom  was 
Pasteur,  adhered  to  it  and  applied  the  term  vaccine  to  emulsions  of 
dead  and  attenuated  bacteria.  While  the  term  vaccine  is  not  accurate, 
in  a  modern  sense,  it  has  crept  into  the  nomenclature  that  deals  with 
agents  which  are  made  up  of  bacterial  suspensions  used  for  the  purpose 
of  creating  immunization. 

In  connection  with  the  study  of  vaccines,  we  must,  first  of  all, 
make  clear  to  ourselves,  that  they  operate  by  efl^ecting  a  condition 
known  as  immunization.  The  study  of  immunity  occupies  a  place 
of  first  importance  in  the  consideration  in  the  well-being  of  the  animal 
economy.  We  cannot  overrate  the  immunity  that  is  natural  or 
physiological.  It  not  only  gives  the  protection  against  bacterial 
invasions  that  are  constant,  but  it  protects  against  the  occasional 
inroads  of  special  forms  if  not  too  numerous  or  too  virulent.  Natural 
immunity  is  relative  but  not  absolute.  There  is  a  constant  conflict 
between  body  cells  and  bacterial  invaders  but,  under  ordinary  con- 
ditions, the  body  cells  contend  with  success.  This  is  known  as  natural 
resistance  or  physiological  immunity.  But  if  the  organism  becomes 
weakened  from  any  cause  and  its  natural  defenses  become  defective, 
the  bacterial  hordes  are  overwhelming,  we  have  disease. 

We  may  establish  a  lasting  immunity  by  a  process  of  adaptation. 


168  VACCINES 

If  our  body  cells  are  vigorous  and  active,  we  may  establish  an  active 
immunity.  This  may  be  done  when  certain  cells  produce  certain 
antibodies  that  neutralize  special  bacteria  or  pathogenic  agents.  It  is 
well  knowTi  that  a  permanent  degree  of  immunity  is  usually  established 
after  a  recovery  from  certain  acute  affections;  among  these  we  may 
name  measles,  scarlet  fever,  smallpox,  typhoid  and  typhus  fevers.  These 
are  among  those  infections  where  the  immunity  is  considered  per- 
manent. Among  other  infections  are  created  an  uncertain  immunity 
if  it  exists  at  all  which  may  be  of  short  duration  and,  in  some  instances, 
appears  to  have  created  a  state  of  hjq^ersusceptibility. 

The  severity  of  the  disease  does  not  always  give  us  a  clue  to  the 
probable  degree  of  lasting  immunity.  A  mild  form  of  the  disease 
may  produce  a  permanent  immunity  and,  in  some  instances,  a  severe 
attack  of  a  disease  does  not  confer  a  lasting  freedom.  It  is,  however, 
a  well-established  fact  that  in  general  an  active  immunity  is  estab- 
lished with  the  use  of  a  modified  antigen  that  will  produce  specific 
antibodies  without  affecting  the  general  health  of  the  subject. 

History. — Our  present-day  vaccine  therapy  began  with  the  vac- 
cination against  smallpox  by  Jermer.  Prior  to  the  discovery  of 
vaccination,  and  since  it  was  the  custom  in  many  European  countries 
to  expose  children  to  mild  cases  of  smallpox  so  that  a  mild  form  of 
the  disease  might  be  acquired,  usually  insuring  a  permanent  immun- 
ity. This  practice  was  not  without  its  dangers,  for  it  was  not  uncom- 
mon that  a  mild  form  of  the  infection  became  severe.  It  had  become 
well  known  that  milk-maids  and  others  milking  cows,  whose  hands 
had  become  infected  through  small  abrasions  with  cow^jox  were 
immune  to  smallpox. 

In  1796,  Edward  Jenner  announced  that  when  a  human  being  was 
inoculated  with  a  very  small  amount  of  cowpox  virus,  it  produced  a 
mild  form  of  the  disease  and  that  this  was  followed  by  absolute  immun- 
ity for  long  periods.  It  was  sho^\Ti  that  when  smallpox  virus  was 
passed  through  a  cow,  it  became  so  attenuated  that  it  would  not 
produce  the  t^i^ical  disease,  but  that  it  had  the  power  to  produce  a 
substance  which  insured  freedom  from  the  disease. 

Jenner  had  made  the  practical  observation  that  smallpox  could  be 
prevented,  but  he  did  not  know  how  the  immunity  was  brought  about. 

It  was  Pasteur,  in  1879,  who  showed  us  by  his  experimental  work 
that  the  virulence  of  microorganisms  could  be  modified  by  exposing 
them  to  light,  high  and  low  temperatures  and,  further,  that  prolonged 
cultivation  could  so  modify  their  virulence,  that  they  could  be  injected 
into  an  animal  without  ill  effects  and  at  the  same  time  bring  about  an 
immunity  by  stimulating  the  protective  mechanism  of  the  host. 

Pasteur  was  aided  by  an  accidental  discovery  while  working  with 
chicken  cholera.  He  was  obliged  to  interrupt  his  work  by  an  absence 
from  home.  On  his  return  he  discovered  that  his  cultures  had  lost 
their  virulence,  that  hens  were  not  greatly  affected  by  the  introduction 
of  a  quantity  that  had  formerly  been  a  fatal  dose.  The  discovery 
that   a   prolonged   cultivation   of   microorganisms   would   attenuate 


VACCINES  169 

them  was  very  great.  It  occurred  to  him  that  in  this  way  a  mild  form 
of  the  disease  could  be  produced  and  that  fowls  might  be  given  a 
quantity  to  prevent  a  severe  attack  of  the  disease.  His  future  work 
proved  the  correctness  of  his  conjectures.  He  found  that  by  attenuat- 
ing the  virulence  of  bacteria  and  their  products,  the  body  cells  could 
be  so  stimulated  that  they  produced  antibodies  that  would  protect 
the  organism  without  producing  the  actual  disease.  All  the  later 
work  of  bacterial  therapy  and  prophylactic  immunization,  rests  to  a 
large  degree  on  these  discoveries. 

Side  Chain  Theory  (Ehrlich). — In  1896  Fode  demonstrated  that  rab- 
bits' blood  in  a  test  tube  free  of  cells  and  phagocytes,  will  destroy 
anthrax  bacilli.  This  led  Buchner  to  the  belief  that  the  bactericidal 
action  of  blood  serum  was  due  to  a  special  body  that  he  called  Alexin. 

Fresh  support  was  given  to  this  theory  by  the  discovery  of  anti- 
toxin by  von  Behring,  chiefly  in  diphtheria. 

Pfeifter  in  1894  added  support  to  the  humoral  theory  by  showing 
that  cholera  vibrios  when  introduced  into  the  peritoneal  cavity  of  a 
guinea-pig,  previously  immunized  against  cholera,  became  liquefied 
apparently  without  the  aid  of  cells  (bacteriolysis).  Bordet  found  a 
"sensitizing  substance"  which  exists  in  immune  serum  and  acts  on 
the  bacteria  against  which  the  animal  has  been  immunized.  A  second 
body  was  shown  to  exist  in  nearly  al  animals  which  he  called  Alexin, 
which  Ehrlich  later  designated  as  coviylement. 

Then  followed  the  attractive  "side  chain  theory."  Ehrlich  attached 
two  functions  to  a  cell.  First  certain  cells,  like  a  nerve  cell  conducts;  a 
gland  cell  secretes,  this  he  called  the  physiologic  function.  Second,  each 
cell  has  the  function  of  nutrition,  waste  and  repair.  The  latter  has  to 
do  with  immunity.  He  believed  that  molecules  of  food  were  seized 
from  the  surrounding  tissues  by  a  "  selective  action  or  chemical  affinity 
between  food  atoms  and  the  portion  of  a  cell  or  side  chain  for  which  it 
has  a  chemical  affinity."  By  this  theory  Ehrlich  sought  to  explain 
the  action  of  toxins  and  the  production  of  antitoxins.  He  assumed 
that  numerous  side-arms  receptors  belong  to  every  cell  molecule. 
Special  cells  anchored  special  toxins.  When  combined  with  side  arms 
or  receptors  in  sufficient  quantity,  the  toxins  may  destroy  the  cell, 
and  if  a  sufficient  number  of  cells  are  killed,  the  death  of  the  host  may 
ensue.  The  cells  produce  receptors  in  large  quantities  and  are  thrown 
off  in  the  blood  stream.  Each  thrown  off  receptor  retains  the  same 
function  of  the  original  receptor,  they  become  free  receptors,  and  they 
combine  chemically  with  their  specific  antigen  neutralizing  it  and 
rendering  it  harmless.  The  antitoxin  consists  of  cast  off  receptors,  or 
antibodies.  The  antigen  must  possess  sufficient  toxic  power  to  stimu- 
late the  cells  in  order  that  sufficient  antibodies  may  be  produced. 

Following  these  epoch-making  discoveries,  an  endless  amount  of 
work  was  done.  While  many  modifications  and  amplifications  have 
followed,  the  fundamentals  have  remained  unchanged.  It  was  shown 
that  disease  might  be  prevented  by  so  cultivating  a  strain  of  patho- 
genic bacteria  and  modifying  and  attenuating   it  that  it  might  be 


170  VACCINES 

injected  and  produced  in  an  extremely  mild  form  of  the  disease 
without  producing  harm,  by  establishing  an  immunity  by  the  produc- 
tion of  antibodies. 

All  earlier  Avork  in  immunity  was  done  on  animals  and  all  experi- 
mental Avork  of  a  similar  character  was  done  in  the  same  way  before 
being  tried  on  the  human  being.  Pasteur  prepared  a  vaccine  of 
anthrax  bacteria  by  attenuation  and  exposure  to  elevated  temperatures 
for  varying  periods  of  time.  The  same  researcher  soon  published  his 
discovery  of  modifying  sections  of  the  spinal  cord  of  infected  rabbits 
who  had  been  infected  with  hydrophobia,  by  a  process  of  drying. 
Out  of  this  method  was  developed  a  prophylactic  that  immunized 
against  the  disease.  Other  vaccines  were  first  produced  in  his  labora- 
torv  which  seemed  to  accord  with  the  principles  that  he  had  laid  down. 


SERUMS. 

Definition. — ^We  must  not  confuse  serum  with  vaccine  therapv.  By 
serum  therapy  is  understood  a  process  of  passive  immunization  for 
the  purpose  of  inducing  a  protective  or  curative  condition.  A  serum 
is  obtained  from  an  animal  that  has  been  immunized  by  the  injection 
of  bacterial  toxins  or  the  microorganisms  themselves.  The  blood  of 
the  immunized  animal  is  withdrawn  and  blood  serum  only  is  injected 
into  the  subject  that  is  to  be  immunized. 


VACCINES. 

Definition. — ^^"accines  or  bacterins  used  for  therapeutic  purposes  are 
made  by  the  injection  directly  into  the  patient  of  pathogenic  bacteria, 
modified  by  certain  processes.  The  difference  between  serums  and 
vaccines  must  not  be  lost  sight  of  and  we  must  not  forget  that  a  serum, 
as  used  here,  is  an  actively  immunized  filtered  blood-serum  free  from 
bacteria.  A  vaccine  is  composed  of  an  emulsion  of  attenuated  or  dead 
bacteria.     Therefore  vaccines  and  serums  are  not  s\Tionymous  terms. 

General  Principles  in  the  Preparation  of  Vaccines.^ — Most  observers 
are  now  agreed  that  the  special  microoorganisms  contained  in  a 
vaccine  should  receive  the  least  possible  modification  or  just  enough 
to  deprive  them  of  their  disease-producing  power.  Any  given  vaccine 
should  be  prepared  by  suspending  a  given  strain  of  microorganisms  in 
a  salt  solution  or  other  vehicle  and  then  expose  them  to  a  degree  of 
heat  that  will  so  change  them  that  they  will  proliferate  no  longer. 
Great  care  must  be  exercised  during  the  heating  process  for  it  has 
been  showTi  that  w^hen  too  much  heat  has  been  applied  the  vaccine 
loses  its  immmiization  qualities. 

There  are  several  ways  that  immunization  may  be  produced  both 
for  prophylactic  and  active  purposes. 

I.  Living  organisms  may  be  introduced  into  the  human  organism. 
This  method  has  not  been  generally  adopted,  for  the  reason,  that  the 


LIPOVACCINES  171 

technic  for  .their  safe  use  is  not  fully  established.  The  results  are 
not  uniform  and  there  is  still  much  experimental  work  necessary 
before  a  standard  will  be  worked  out  so  that  the  method  may  be  used 
safely  by  the  profession. 

II.  Modified  or  attenuated  microorganisms  are  now  more  generally 
in  use.     They  are  prepared  by  one  of  the  following  methods: 

1.  The  microorganisms  are  passed  through  lower  animals  by  inject- 
ing them  into  the  general  circulation. 

2.  The  most  frequent  method  of  preparing  vaccine  is  by  suspension 
of  microorganisms  that  are  exposed  to  heat  after  being  grown  on 
culture  media,  and  then  are  modified  by  heat  to  a  point  at  or  just  short 
of  producing  their  deaths.  Long  exposure  to  cold  may  attenuate  the 
organisms  in  the  same  way.  Whichever  method  is  used,  exposure  to 
heat  or  cold,  great  care  must  be  exercised  to  avoid  actual  microorganic 
death  because  a  suspension  of  dead  organisms  under  some  conditions 
may  have  no  more  effect  than  the  salt  solution  in  which  they  are 
suspended. 

3.  Microorganisms  are  attenuated  when  exposed  to  light  and  air 
(chicken  cholera). 

4.  Microorganisms  are  attenuated  when  they  are  dessicated  or  dried. 
The  longer  they  are  dried  the  greater  the  attenuation  (rabies). 

5.  Some  vaccines  are  prepared  by  exposing  microorganisms  to  ele- 
vated temperatures  for  varying  periods  of  time  (anthrax). 

6.  Chemical  germicides  are  employed  to  modify  certain  micro- 
organisms (anthrax — Roux)  (diphtheria — Behring). 

III.  Bacterial  constituents,  the  soluble  toxins  and  products  of  bac- 
terial autolysis  as  used  by  Koch  in  the  preparation  of  tuberculin,  etc. 

LIPOVACCINES. 

The  success  of  prophylactic  vaccines  in  a  number  of  infectious 
diseases  is  acknowledged  by  all  well-informed  practitioners  of  medicine 
and  surgery.  One  of  the  drawbacks  has  been  the  more  or  less  severe 
local  and  general  reactions  in  some  cases  after  the  initial  dose,  so  that 
many  cases  refused  to  return  for  subsequent  inoculations.  The  pro- 
fession knows  that  in  1885,  Ferran  in  Spain,  vaccinated  many  thousands 
against  cholera;  in  India,  Hafltkine  successfully  dealt  with  plague  and 
Shiga  in  Japan  with  excellent  results  inoculated  against  dysentery. 
The  epoch-making  results  obtained  in  our  Army  with  typhoid  and 
paratyphoid  vaccines  are  well  known.  The  severe  reactions  sometimes 
observed  have  created  much  prejudice  in  the  popular  mind. 

Various  expedients  have  been  employed  to  solve  the  problem  among 
them  Le  Moignie  and  Piony  substituted  oils  for  physiologic  sodium 
chlorid  solution  commonly  employed  in  making  vaccines.  The  term 
lipovaccines  has  come  into  general  use.  The  lipoid  oil  menstruum  carry- 
ing the  vaccine  seems  to  delay  the  absorption  so  that  the  system  is  not 
so  suddenly  overwhelmed.  Le  Moignie  and  Piony  demonstrated  that 
three  and  four  of  the  usual  doses  of  lipovaccine,  could  be  injected 


172  VACCINES 

without  marked  reaction  producing  an  immunity  equal  to  that  of 
repeated  injections  of  the  usual  saline  vaccines.  Further,  it  was  shown 
that  vaccines  made  with  oil,  do  not  deteriorate  and  have  the  further 
advantage  of  enabling  the  safe  use  of  mass  injections  when  so  desired. 
Several  lipovaccines  have  been  produced.  There  is  no  doubt  that 
vaccines  in  oil  will  answer  some  of  the  objections  that  have  been  urged 
against  the  vaccine  treatment  of  several  infectious  diseases. 

OPSONINS. 

While  our  early  ideas  of  immunization  were  so  closely  linked  with 
Metchnikoff's  idea  of  phagocytosis,  we  were  very  soon  obliged  to 
modify  these  views  because  it  was  shown  that  substances  in  the  body 
fluids  increased  the  phagocytic  process.  It  was  observed  that  when 
leukocytes  were  deprived  of  their  fluids  they  became  powerless  to 
take  up  and  destroy  the  pathogenic  microorganisms.  If  they  were 
placed  in  fresh  serum,  their  phagocytic  power  was  restored.  Metch- 
nikoff  believed  this  power  to  be  due  to  a  body  that  he  termed  "  stimu- 
lins"  and  believed  they  changed  leukocytes  to  phagocytes.  This 
view  was  given  up  for  a  later  observation  which  seemed  to  show  that 
the  phagocytes  were  not  facilitated  to  increase  their  powers  to  take  up 
bacteria  but  that  the  microorganisms  were  prepared  so  that  they  could 
more  easily  be  taken  up.  Denys  and  Leclef,  1895,  suggested  that 
these  bodies  in  the  serum  neutrahzed  the  exotoxins  and  endotoxins  of 
bacteria  that  caused  a  negative  chemotactic  influence,  in  that  way 
deprived  them  of  two  resisting  powers  exposing  them  to  increased 
phagocytosis. 

In  1903  Wright  and  Douglas  again  demonstrated  that  phagocytosis 
was  increased  when  bacteria  were  subjected  to  the  action  of  serum. 
They  first  determined  that  phagocytosis  depended  on  some  specific 
substance  in  the  blood  and  further  that  the  bacteria  themselves 
were  acted  upon,  so  that  they  could  more  easily  be  devoured  by  the 
leukocytes.  This  substance  they  named  opsonin.  This  body  is  a 
constituent  of  normal  serum.  Neufeld  and  Rimpan  obtained  similar 
results  in  working  with  immune  serums,  they  named  this  substance 
bacteriotropin. 

Definition.— Opsonins  are  substances  in  normal  and  immune  serums 
which  act  upon  bacteria  and  other  cells  in  such  a  manner  as  to  prepare 
them  for  more  ready  ingestion  by  the  phagocytes  (Kolmer).  Opson- 
ins are  found  in  varying  amounts  and  of  different  varieties  for  different 
bacteria  in  normal  serum.  Apparently  opsonins  are  more  or  less 
specific  for  different  bacteria.  All  bacteria  are  not  equally  prone  to 
opsonification.  The  profession  generally  recognizes  the  importance 
of  opsonins  in  their  relation  to  phagocytosis  in  the  process  of  immuni- 
zation. 

Wright  and  Douglas,  who  have  greatly  illumined  this  chapter  by 
their  I'esearches,  have  perfected  a  technic  for  detecting  the  presence 
of  opsonins  and  their  quantity  in  the  body  fluid  and,  further,  a  method 


OPSONINS  173 

for  increasing  the  opsonins  and  thereby  the  phagocytic  process  which 
they  have  designated  by  the  opsonic  index. 

Opsonic  Index. — According  to  George  P.  Sanborn,  Wright's  method 
of  determining  the  opsonic  index  is  as  follows :  "  Into  a  capillary  pipet, 
with  a  rubber  teat  affixed,  are  drawn  equal  vohunes  of  the  blood  serum 
of  a  normal  individual,  of  blood  corpuscles  which  have  been  washed 
free  from  serum,  and  of  an  emulsion  of  bacteria  against  which  it  is 
desired  to  determine  the  opsonic  power  of  the  patient's  serum.  Each 
of  these  three  volumes  is  drawn  into  the  pipet  separated  by  an  air 
bubble,  and  then  expressed  upon  a  slide,  mixed  thoroughly,  drawn  into 
the  pipet  again.  The  pipet  is  sealed  in  a  flame  and  incubated  for 
fifteen  minutes  at  37.5°  C. 

A  similar  procedure  is  carried  out,  using  the  same  corpuscles  and 
the  same  emulsion  of  bacteria,  but  the  patient's  serum  instead  of  the 
normal,  and  incubation  is  carried  out  for  the  same  length  of  time. 
These  pipets  are  removed  at  the  end  of  the  incubation  period,  the 
small  end  broken  off  and  the  contents  expressed  upon  a  clean  slide, 
mixed  thoroughly  and  a  small  drop  of  this  mixture  placed  upon  a  clean 
slide  and  a  smear  made.  Each  of  the  mixtures  is  treated  in  this  way. 
If  the  smears  are  then  stained  and  the  leukocytes  scrutinized,  it  will 
be  found  that  they  have  ingested  numbers  of  bacteria  in  each  of  the 
specimens.  All  bacteria  contained  in  100  leukocytes  in  the  case  of 
each  slide  are  counted  and  the  average  number  ingested  by  each 
leukocyte  is  calculated.  This  number  is  termed  the  phagocytic  index. 
The  opsonic  index  is  determined  by  dividing  the  average  number  of 
bacteria  per  leukocyte,  which  have  been  ingested  in  the  experiment 
with  the  patient's  serum,  by  the  average  number  ingested  when  the 
normal  blood  stream  is  used.  The  resulting  figure  representing  the 
ratio  between  the  phagocytic  power  of  the  patient's  and  the  normal 
serum,  the  normal  serum  being  considered  as  the  unit.  An  opsonic 
index,  therefore,  of  1.5  indicates  that  the  effective  phagocytic  power 
or  opsonic  power  of  the  patient's  blood  is  one  and  a  half  times  that 
of  a  normal  individual.  If  the  result  of  the  division  is  0.5,  it  shows 
that  the  effective  phagocytic  or  opsonic  power  of  the  patient's  serum 
is  just  half  that  of  the  normal  individual.  In  order  to  obtain  an 
average  normal  serum,  it  is  the  custom  to  mix  the  blood  serum  of 
several  individuals  who  are  known  not  to  be  infected  with  the  particu- 
lar organism  in  question." 

Wright  states  that  when  the  opsonic  power  is  elevated  above  the 
normal,  it  is  indicative  of  a  favorable  response  of  the  immunizing 
mechanism. 

We  may  conclude  that  the  organism  can  adapt  itself  to  poisonous 
influences  of  different  kinds,  according  to  their  chemical  nature.  We 
find  that  particular  cells  or  groups  of  cells  harbor  this  mechanism 
of  adaptation.  Such  cells  have  the  ability,  when  stimulated  by 
poisonous  stimuli,  to  produce  bodies  that  are  carried  by  the  blood 
stream,  enabling  them  to  destroy  such  stimuli  if  they  are  of  a  bacterial 
nature. 


174  VACCINES 

Method  for  Preparing  Bacterial  Vaccines. — When  preparing  vac- 
cines, infected  material  must  be  procured  from  suitable  subjects. 
Pure  cultures  must  be  made  of  the  bacteria  that  are  producing  the 
disease.  The  cultures  must  be  suspended  in  a  saline  solution  or  oil 
and  a  preservative  is  added  before  placing  the  prepared  vaccine  in 
suitable  containers. 

In  procuring  infected  material  contamination  must  be  avoided. 
Every  care  must  be  exercised  to  procure  material  that  is  apparently 
causing  the  disease.  When  possible  material  for  making  vaccines 
should  be  obtained  from  closed  cavities.  If  pus  from  an  abscess 
cavity  is  to  be  used,  touching  the  surrounding  skin  must  be  avoided, 
the  material  should  be  only  from  pus  contained  in  the  abscess  and 
not  from  the  surrounding  skin  and  other  structures.  We  wish  to 
obtain  only  the  bacteria  that  are  responsible  for  the  suppuration. 
We  wish  to  secure  the  Staphylococcus  aureus  or  citreus  and  not  the 
Staphylococcus  epidermidis  albus.  Therefore,  we  should  prepare  the 
surrounding  skin  as  for  any  other  operation  with  Harrington  solution 
or  tincture  of  iodine.  If  the  material  is  to  be  secured  from  the  nose, 
the  nasal  cavities  should  be  carefully  prepared  as  if  for  an  operation. 
The  secretions  to  be  used  for  the  vaccine  may  be  procured  by  rubbing 
a  sterile  cotton  swab  on  the  undersurface  of  the  turbinated  bones  and 
septum.  If  from  the  ear,  the  auditory  canal  should  be  free  of  all 
excess  secretions,  the  pus  from  which  the  culture  is  to  be  made  should 
be  taken  with  a  sterile  cotton  swab  from  the  infected  areas.  If  we 
wish  to  secure  cultures  from  infected  lung  tissues  where  there  is  no 
sputum  or  where  it  is  clear  that  the  sputum  has  no  direct  connection 
with  the  diseased  areas,  a  sterilized  glass  syringe  with  a  long  needle 
may  be  used  to  obtain  the  desired  substance.  The  skin,  over  the 
infected  area,  is  carefully  disinfected  as  for  any  surgical  procedure. 
A  puncture  with  the  needle  is  made  into  the  infected  pulmonary  tissue. 
Some  authors  recommend  that  the  syringe  should  contain  peptone 
broth,  and  after  the  needle  has  reached  a  desired  depth,  1  c.c.  of  the 
broth  should  be  injected  into  the  lung  structures  and  after  a  lapse  of 
a  few  seconds,  it  should  be  drawn  back  into  the  s;>Tinge.  This  aspi- 
rated material  is  then  to  be  used  to  make  the  vaccine.  The  usual 
method  of  collecting  sputum  does  not  always  lead  to  satisfactory  results. 
The  ordinary  expectorations  are  mixed  with  microorganisms  from  the 
buccal  cavity,  teeth,  tonsils  and  postnasal  spaces.  To  obtain  the 
best  results,  the  teeth  should  be  brushed  with  a  sterile  brush,  the 
mouth  and  throat  washed  with  sterile  water  several  times.  Water 
should  be  swallowed  to  clean  the  pharjiix.  Then  the  sputum  is  to 
be  expectorated  into  a  wide-mouthed  sterile  bottle. 

When  collecting  urine,  the  most  satisfactory  results  are  obtained 
by  catheterization  with  a  sterile  catheter  after  the  meatus  has  been 
carefully  cleansed. 

Blood  is  best  obtained  from  a  conspicuous  vein  at  the  bend  of  the 
elbow.  After  the  skin  has  been  carefullv  sterilized,  a  quantity  may 
be  withdrawn  with  a  sterile  syringe. 


OPSONINS  175 

Making  Pure  Cultures. — By  this  is  meant  a  technic  that  will  enable 
one  to  secure  the  one  or  more  varieties  of  organisms  that  cause  a  cer- 
tain process.  To  separate  the  chief  offenders  from  other  microorgan-  ■ 
isms  is  often  a  most  difficult  task  but,  if  we  desire  a  certain  effect,  it 
is  necessary,  that  the  specific  organisms  be  procured  that  will  produce 
the  desired  antibodies.  No  one  method  can  be  followed  for  all  varie- 
ties of  bacteria.  Briefly,  the  following  methods  have  proved  to  be 
practical. 

The  nature  of  the  infection  may  sometimes  be  found  in  stained 
smears  of  the  secretions  of  the  disease.  Often  an  isolation  of  the 
specific  germ  may  be  effected  by  making  plate  cultures  on  solid 
media.  Primary  cultures  may  be  developed.  The  pus  from  newly 
incised  abscesses,  or  microorganisms  in  the  urine  or  urethral  discharges 
or  secretions  from  the  throat  in  influenza  or  sputum  in  pneumonia, 
may  exhibit  the  characteristic  microorganisms.  The  best  culture 
media  are  those  that  contain  blood  serum. 

Solid  media  are  best  suited  for  the  preparation  of  vaccines. 

Slant  agar  tubes  are  frequently  used  in  making  bacterial  vaccines. 
Two  tubes  may  be  used  for  rapidly  growing  bacteria  and  six  or  more 
are  used  for  more  slowly  growing  organisms  such  as  pneumococci  and 
streptococci. 

Shorter  or  longer  periods  are  necessary  to  grow  cultures;  the  time 
depends  on  the  special  organism.  Usually  twenty-four  hours  in  an 
oven  at  a  temperature  at  37°  C.  and  less  time  for  those  that  grow 
more  rapidly. 

When  cultures  have  been  developed  in  the  incubator,  specimens 
from  each  colony  are  stained  and  examined  in  order  to  find  the  organ- 
ism that  causes  the  infection. 

It  has  been  the  practice  to  employ  an  attenuated  culture  where  the 
original  organism  is  virulent,  A  second  strain  has  been  found  to  be 
safe  in  cases  of  certain  streptococci  and  of  pneumococci,  etc. 

When  the  cultures  have  become  fully  developed,  the  next  step  is 
to  make  an  emulsion.  This  must  be  done  with  aseptic  care.  Take  a 
test-tube  of  sterile  normal  salt  solution  and  pour  it  on  the  surface  of 
the  slant  tube  containing  the  culture,  then  shake  the  tube  so  as  to 
cause  the  microorganisms  to  become  suspended.  If  the  culture 
adheres  to  the  medium,  it  may  be  separated  with  the  aid  of  a  platinum 
loop.  The  loop  must  be  used  with  care  so  as  to  remove  only  the 
bacteria  from  the  medium.  The  emulsion  thus  formed  is  poured  on 
the  surface  of  the  second  culture  causing  the  latter  to  be  suspended 
and  add  more  salt  solution  if  indicated.  The  entire  series  of  cultures 
are  suspended  in  the  same  way.  The  last  suspension  is  then  poured 
into  a  heavy  flask  containing  glass  beads.  This  flask  is  then  shaken 
by  hand  or  a  mechanical  shaker  until  the  bacterial  contents  have  been 
disintegrated  and  the  emulsion  has  become  thoroughly  homogeneous. 
In  order  to  be  certain  that  the  emulsion  contains  no  large  particles, 
it  should  be  centrifugalized  or  filtered  through  a  sterile  filter.  Culture 
media  that  contain  peptone  may  develop  toxic  bodies  that  sometimes 


176  VACCINES 

produce  anaphylaxis.  "In  addition,  when,  in  the  preparation  of  a 
vaccine,  bacteria  grown  on  a  serum  medium  are  washed  off  with 
normal  salt  solution,  a  portion  of  the  serum  may  be  removed  and  in 
this  way  be  capable  of  producing  disagreeable  local  and  general  reac- 
tions. For  these  reasons  it  is  advisable  to  wash  all  suspensions  by 
repeated  centrifugalizations  until  the  supernatant  fluid  reacts  nega- 
tively to  the  biuret  or  ninhydrin  reaction."     (Willard  Stone,  Kolmer.) 

Standardization  and  counting  of  bacteria  in  suspension  in  a  given 
quantity  of  fluid  is  done  by  several  methods  and  while  it  might  be  of 
interest  to  describe  several  procedures,  it  will  suffice  for  our  purpose 
to  detail  only  one,  viz.,  that  of  Wright  as  described  by  Kolmer. 

"Method  of  Wright. — Prepare  a  simple  capillary  pipette,  making  a 
mark  on  its  stem  about  one  inch  from  its  tip,  and  fit  a  rubber  teat  to 
its  barrel.  Cleanse  and  prick  the  finger,  press  out  a  drop  of  blood, 
take  up  the  pipette  and  draw  up  into  it  first  one  volume  of  sodium 
citrate  solution,  one  of  blood  and  then  one  volume  of  bacterial  sus- 
pension or  two  or  more  volumes,  if  it  appears  on  inspection  to  contain 
much  fewer  than  500,000,000  of  bacteria  to  the  cubic  centimeter. 
To  guard  against  crimping  of  the  corpuscles  in  drying  the  film,  Wright 
advocates  aspirating  one  or  two  volumes  of  distilled  water  after  the 
blood  and  bacterial  suspension. 

Now  expel  from  the  pipette  first  only  the  distilled  water  and  the 
bacterial  emulsion,  and  mix  these,  so  that  there  may  be  no  danger  of 
the  red  corpuscles  becoming  hemolized  and  then  proceed  to  mix 
together  the  whole  contents  of  the  pipette,  aspirating  and  re-expelling 
these  a  dozen  times.  Then  make  two  or  three  microscopic  films 
from  the  mixture  spreading  these  out  on  slides  that  have  been  rough- 
ened with  emery. 

The  films  are  dried  in  the  air,  fixed  by  immersing  them  for  two 
minutes  in  a  saturated  solution  of  corrosive  sublimate,  washed  thor- 
oughly and  stained  for  a  minute  with  carbolfuchsin  diluted  1  :  10  or 
carbolthionin  for  two  to  five  minutes  and  then  washed  and  dried. 

The  films  are  now  given  a  preliminary  examination.  If  red  corpus- 
cles and  bacteria  are  found  in  approximately  the  same  numbers  and 
the  suspension  is  free  from  bacterial  aggregates,  the  count  may  be 
made.  If  either  of  the  bacteria  or  the  corpuscles  are  largely  in  excess, 
new  mixtures  and  new  films  must  be  made.  In  case  the  bacteria  are 
gathered  in  clumps,  the  suspension  should  be  shaken  again  and  new 
film  prepared. 

When  satisfactory  films  have  been  obtained,  the  actual  counting 
may  be  done.  This  is  carried  out  with  an  oil-immersion  lens,  and  in 
order  to  secure  accuracy,  it  is  necessary  to  restrict  or  divide  the  field 
by  a  small  square  diaphragm  made  of  paper  or  cardboard,  or  by 
inscribing  lines  on  a  small  clean  cover-glass  and  dropping  them  on  a 
diaphragm  of  the  eye-piece. 

The  field  is  now  chosen  at  random,  and  the  corpuscles  and  bacteria 
are  counted,  the  results  being  jotted  doA\Ti  on  a  sheet  of  paper.  Pro- 
ceed at  random  from  field  to  field,  traversing  every  part  of  the  slide. 


OPSONINS  177 

Establish  a  rule  for  counting  corpuscles  that  transgress  or  touch  the 
edge  of  the  field.  Eliminate  from  consideration  any  parts  of  the 
film  in  which  the  preparation  is  unsatisfactory  as  regards  staining  or 
with  respect  to  the  integrity  of  the  red  corpuscles.  The  examination 
is  continued  until  at  least  500  corpuscles  have  been  counted,  half  of 
the  coimt  being  made  from  the  second  slide.  The  number  of  micro- 
organisms is  now  totalled,  and  the  approximate  number  per  cubic 
centimeter  estimated.  Let  us  assume,  for  example,  that  600  red 
cells  and  1200  bacteria  have  been  counted.  A  cubic  millimeter  of  blood 
contains  5,500,000  red  corpuscles,  and  equal  volumes  of  blood  and 
emulsion  were  taken.     A  cubic  millimeter  of  the  emulsion,  therefore, 

,.         ^    5,500,000    X    1200  ,  .    r,r,r,  c^r,  '  .-  M,- 

contamed w^ =  11,000,000  organisms  per  cubic  milli- 
meter or  11,000,000,000  per  cubic  centimeter." 

Vaccines  are  sterilized  and  their  sterility  tested  after  the  prelimi- 
nary examination.  Heat  is  the  usual  agent  employed,  germicides  are 
likewise  used.  "When  the  films  for  counting  are  satisfactory,  the 
vaccine  is  transferred  to  a  test-tube.  The  latter  is  sealed  and  placed 
in  a  water-bath,  care  being  taken  that  the  whole  tube  is  immersed. 
In  the  process  of  sterilization,  pains  must  be  taken  to  employ  the 
lowest  possible  temperature  and  the  shortest  possible  time  to  produce 
sterility.  The  usual  temperature  is  between  50°  and  60°  C,  if  no 
more  than  an  hour  to  complete  the  process. 

Cultures  should  then  be  made  of  the  vaccine  to  ascertain  its  sterile 
condition.  A  dozen  or  more  loopfuls  are  then  placed  on  slant  culture 
mediums  of  blood  serum  or  blood  agar.  The  tubes  are  then  placed 
in  a  culture  oven  for  twenty-four  or  more  hours,  the  time  depending 
on  whether  the  organisms  are  rapid  or  slow-growing  ones.  If  the 
following  examination  indicates  sterility,  the  vaccine  is  finished.  If 
not  sterile,  more  heat  must  be  applied  or  a  new  one  is  made. 

If  the  vaccine  is  found  to  be  satisfactory,  it  must  be  diluted  with  a 
sterile  saline  solution  so  that  each  centimeter  contains  a  definite 
number  of  organisms.  A  portion  of  the  prepared  vaccine  is  diluted 
and  the  remainder  is  saved  in  case  the  dose  is  to  be  modified  in  the 
subsequent  treatment  of  the  cases.  If  a  vaccine  of  Staphylococcus 
aureus  contains  1,500,000,000  organisms  per  cubic  centimeter  and  the 
dose  decided  upon  is  500,000,000  per  cubic  centimeter,  sufficient  vac- 
cine for  thirty  doses  is  prepared  by  withdrawing  10  c.c.  of  vaccine 
in  a  sterile  container  and  adding  20  c.c.  of  sterile  salt  solution.  The 
mixture  is  agitated  to  insure  thorough  mixing,  and  0.1  c.c.  of  a  1  :  100 
dilution  of  phenol  is  added  to  each  cubic  centimeter  of  vaccine  as  a 
preservative.  (Kohner.)  The  vaccine  should  be  kept  in  a  sterile 
bottle,  closed  •^'ith  a  rubber  cap.  WTien  a  dose  is  to  be  given,  the 
rubber  cap  is  painted  with  tincture  of  iodine.  The  needle  is  thrust 
through  the  rubber  and  the  desired  amount  is  dra^\^l  out  with  an 
aseptic  sjT-inge.  Flexible  collodion  is  applied  over  the  needle  punc- 
ture. Frequently  vaccines  are  placed  in  ampoules,  each  one  containing 
a  single  dose.     These  ampoules  must  be  sealed  by  heat. 

VOL.  1—12 


178  VACCINES 

Sensitized  Bacterial  Vaccines.- — Sensitized  bacterial  vaccines  are  pre- 
pared by  first  immunizing  a  rabbit  with  subcutaneous  injections  of 
microorganisms  which  have  been  killed  by  heat.  Increasing  doses 
are  given  until  the  animal  withstands  living  organisms  intravenously. 
The  animal  is  then  bled  and  the  serum  is  mixed  equal  parts  with 
emulsions  of  bacteria.  After  being  thoroughly  mixed  and  centrifugal- 
ized,  washed  and  tested  for  sterility,  counted  and  suspended  in  normal 
salt  solution,  the  sensitized  vaccine  is  ready  for  use. 

Method  of  Administration. — An  all-glass  sterile  syringe  is  used  to 
administer  bacterial  vaccines.  The  syringe  should  have  a  sharp 
platinum-iridium  needle.  Vaccines  are  best  given  in  the  early  part  of 
the  day  because  they  are  often  followed  by  depression  and  ill  feeling. 
These  s^Tnptoms  pass  away  in  a  few  hours  and  will  have  disappeared 
by  night  so  that  the  patient  will  have  a  better  night's  rest.  Injections 
are  best  given  in  loose  areolar  tissues  and  at  such  points  where  there 
is  a  minimum  amount  of  muscular  movement  and  where  the  clothing 
causes  the  least  discomfort. 

The  points  of  election  are  below  the  clavicle,  upper  margin  of  the 
buttocks,  along  the  ]McBurney  line.  The  skin  is  first  disinfected  with 
soap  and  water  or  tincture  of  iodine.  The  skin,  at  the  point  of  injec- 
tion, is  raised  between  the  thumb  and  finger  and  the  needle  is  then 
thrust  into  the  subcutaneous  tissues  between  the  raised  layers  of  skin. 

In  the  greater  number  of  cases,  there  is  a  local  irritation  of  the  skin 
at  the  point  of  injection. 

The  site  of  the  injections  sometimes  shows  a  decided  reaction  after 
an  inoculation,  this  is  known  as  a  focal  effect.  Such  a  reaction,  as 
shown  by  increased  redness,  may  serve  as  a  guide  for  further  dosage. 
A  decided  reaction  indicates  decreased  dosage.  The  general  systemic 
effects  vary  greatly  in  different  subjects.  An  indicated  dose  usually 
produces  more  or  less  exhaustion,  fever,  headache  and  accelerated 
pulse-rate. 

We  are  still  undecided  in  reference  to  frequency  and  exact  dosage. 
Each  case  must  be  judged  by  itself.  Since  the  opsonic  index  has  been 
found  impracticable  in  general  practice,  we  must  depend  on  the  reac- 
tion of  the  patient  to  each  dose  and  the  general  condition  for  which  he 
is  treated.  It  can  be  easily  understood  that  in  very  acute  infections, 
particularly  when  occurring  in  weakened  persons,  a  small  and  safe 
dose  is  indicated.  All  therapeutic  vaccines  should  be  used,  in  their 
initial  dose,  in  minimum  amounts.  Begin  with  a  safe  dose  and,  if 
there  is  no  reaction  in  forty-eight  hours,  a  larger  one  may  be  given. 
Should  local  or  general  s^TQptoms  follow  the  first  inoculation,  a  second 
one  of  the  same  size  may  be  administered  in  four  to  six  days.  It  must 
be  borne  in  mind  that  fresh  infections  by  other  organisms  may  occur, 
and  if  it  does,  new  vaccines  should  be  made,  in  order  that  the  anti- 
bodies for  the  new  invaders  may  be  included. 

Sometimes  there  is  a  decided  and  severe  reaction  after  the  initial 
dose  which  would  indicate  that  a  negative  phase  had  been  induced 
which  is  a  period  of  lowered  opsonic  power,  of  lowered  resistance,  in 


SEPTICEMIA  179 

fact,  the  use  of  too  large  doses  of  vaccines,  is  manifested  at  once  by 
local  changes,  which  show  that  the  process  is  increasing.  On  the 
other  hand,  if  there  is  an  amelioration  of  the  general  symptoms,  we 
have  a  period  of  increased  resistance,  of  elevated  opsonic  power,  known 
as  the  positive  phase. 

It  is  often  difficult  to  decide  the  intervals  between  the  inoculations. 
The  tendency  is  to  repeat  them  with  too  great  frequency.  The  better 
plan  is  to  underdo  than  overdo. 

The  dose  of  the  vaccine  varies  somewhat  in  the  kind  of  organisms 
involved  in  the  infection  and  also  whether  the  process  is  acute  or 
chronic.  In  acute  cases  the  dose  is  smaller  and  given  oftener  and 
in  chronic  cases  it  is  large  and  in  longer  intervals.  The  age  and 
weight  of  the  patient  are  also  determining  factors.  When  in  doubt 
begin  with  small  doses  and  increase  or  diminish  according  to  the 
local  and  general  reaction.  Repetition  of  doses  depend  upon  the 
reaction  and  the  results  obtained. 

The  following  list  is  offered  as  a  suggestion  as  to  dosage  for  vaccines. 

Staphylococcus  aureus 100,000,000  to  1,000,000,000 

Staphylococcus  albus  and  citreus        ....  200,000,000  to  1,000,000,000 

Streptococcus  pyogenes 25,000,000  to     200,000,000 

Gonococcus 25,000,000  to      200,000,000 

Typhoid  bacillus '    .      .  250,000,000  to  1,000,000,000 

Colon  baciUus 100,000,000  to  1,000,000,000 

Under  the  following  heads  several  infectious  conditions  usually 
known  as  surgical  infections  have  been  briefly  considered,  and  their 
treatment  with  bacterial  vaccines  have  been  indicated. 

The  vaccine  treatment  of  tuberculosis  has  been  omitted  for  the 
reason  that  the  effects  of  heliotherapy  and  an  atmosphere  compara- 
tively free  from  pathogenic  microorganisms,  general  hygienic  sur- 
roundings, and  diet  have  shown  increasingly  brilliant  results,  both  in 
surgical  as  well  as  in  pulmonary  tuberculosis.  Vaccines,  both  bacterial 
and  non-bacterial,  have  not  fulfilled  our  optimistic  expectations,  espe- 
cially in  tuberculous  affections.  In  the  light  of  our  present  knowledge 
of  their  effects  they  can  only  play  a  subsidiary  role. 

SEPTICEMIA. 

In  septicemia  we  give  vaccines  subcutaneously  to  produce  a  reaction 
followed  by  an  increased  immunity.  But  before  proceeding  with  the 
use  of  vaccines  we  must  determine  whether  we  have  to  do  with 
bacteria  that  originate  in  an  active  focus  of  infection,  such  as  a  deep- 
seated  abscess  or  that  form  in  which  the  bacteria  appear  to  be  growing 
in  the  blood  stream.  If  the  infection  originates  in  a  definite  focus, 
there  is.  a  constant  addition  of  bacteria  to  the  blood  stream,  and  we 
may  speak  of  continuous  auto-inoculation.  We  must  place  under 
this  head  acute  fulminating  infections  and  also  carbuncle,  phlegmon, 
erysipelas  and  others.  The  other  class  comprises  infections  whose 
source  is  clinically  not  demonstrable  and  where  the  point  of  infection 


180  VACCINES 

cannot  be  removed  or  drained.  These  are  the  true  septicemias.  It  is 
clear  that  before  the  treatment  of  septicemia  is  begmi,  the  locus  of 
infection  when  found  must  be  attacked  and  eradicated  or  drained  or 
both.     We  cannot  hope  for  success  if  this  is  not  done. 

Diagnosis. — It  is  important  to  make  a  bacteriological  diagnosis  when 
possible.  It  is  desirable  to  determine  whether  our  septicemia  is  due  to 
a  streptococcus,  staphylococcus  or  other  organisms.  Having  found 
the  pathogenic  micrococci  the  usual  technic  well  known  to  all  labora- 
tory' workers  must  be  employed  with  the  view  of  preparing  an  autog- 
enous vaccine.  Agar,  as  a  medium,  for  blood  cultures  of  a  pneu- 
mococcus,  the  most  common  factor  in  septicemia,  has  been  successfully 
used  by  Rosenow.  Both  solid  and  liquid  media  have  given  satisfactory 
results.  The  methods  for  their  preparations  have  been  indicated  in  the 
preceding  pages. 

Prognosis. — That  the  prognosis  is  different  in  these  two  types  of 
septicemia  is  evident.  When  we  can  eliminate  by  early  operation  the 
source  of  auto-inoculation,  the  chances  for  recovery  are  good.  In 
the  true  septicemias  the  point  of  auto-inoculation  is  beyond  our  control. 
The  blood  current  appears  to  be  a  favorable  medium  for  bacterial 
growth.     The  prognosis  is  correspondingly  grave. 

Dose. — When  possible  be  guided  by  the  opsonic  index,  but  septi- 
cemia may  be  successfully  treated  by  taking  into  account  the  clinical 
manifestations.  We  must  guard  against  overdosage  on  account  of  the 
danger  of  overstimulation  which  may  be  inimical  to  the  protective 
mechanism.  Therefore,  prudence  would  dictate  that  the  initial  dose 
be  small.  In  streptococcic  septicemia,  the  primary  dose  should  not  be 
over  1,000,000  to  2,000,000  and  be  repeated  in  twelve  to  twenty-four 
hours  if  no  unpleasant  symptoms  develop.  The  increase  in  dosage 
depends  on  the  resulting  reaction.  If  no  untoward  conditions  appear, 
the  dose  may  be  increased  from  day  to  day  until  the  maximum  of 
25,000,000  daily  has  been  reached.  As  improvement  takes  place,  it 
may  be  well  to  repeat  the  dose  every  second  day  and  even  longer.  We 
must  not  always  be  guided  by  the  number  of  bacteria  contained  in  a 
given  dose  but  rather  by  the  effect  that  each  dose  produces.  A  good 
rule  to  follow  is,  the  more  ill  the  patient,  the  smaller  the  initial  dose. 
If,  in  the  course  of  the  treatment,  there  is  a  sudden  aggravation  of 
toxic  symptoms  as  is  shown  by  a  rise  in  temperature  and  increased 
prostration,  the  next  dose  must  be  smaller  and  the  interval  between 
the  doses  should  be  increased. 

SUPPURATIVE    ARTHRITIS. 

In  these  conditions  the  microorganisms  found  are  the  staphylococcus, 
streptococcus  and  pneumococcus.  As  soon  as  the  condition  is  recog- 
nized, we  must  attack  the  local  condition  either  by  the  injections 
of  solution  of  formaldehyde  according  to  Murphy,  or  by  the  establish- 
ment of  thorough  drainage.  If  this  is  not  done  promptly,  the  function 
of  the  joint  is  endangered  no  matter  how  carefully  the  vaccine  therapy 


nUEUMATIC  ARTHRITIS  181 

has  been  employed.     The  details  of  the  surgical  management  need 
not  be  discussed  here  but  it  is  of  first  importance. 

If,  in  spite  of  thorough  surgical  measures,  the  infection  does  not 
subside,  and  we  can  find  no  other  locus  of  infection  or  if  the  septicemia 
becomes  chronic,  an  appropriate  autogenous  or  stock  vaccine  may  be 
employed.  The  dose  should  be  small  and  their  size  and  frequency 
regulated  according  to  the  effects  on  the  local  and  general  conditions. 

GONORRHEAL    ARTHRITIS. 

The  majority  of  the  cases  of  this  type  of  infection  when  acute  subside 
by  immobilization  and  rest  in  bed.  In  the  initial  stage  of  this  infec- 
tion, we  have  a  more  or  less  auto-inoculation  but  it  soon  becomes 
localized.  Vaccines  are  usually  not  indicated  in  the  acute  stage,  but 
they  have  been  used  with  success.  When  the  case  becomes  chronic, 
a  vaccine  may  become  a  stimulus  and  incite  the  protective  mechanism. 
Many  observers  testify  to  the  efficiency  of  gonococcus  vaccines 
and  speak  highly  of  their  use.  Hartwell^  tabulated  31  cases.  He 
treated  these  cases  for  periods  varying  from  one  month  to  one  year. 
He  described  27  cases  as  having  completely  functionating  joints. 
The  others  had  ankylosed  joint  of  varying  degrees  when  the  treatment 
began.  He  gave  doses  as  high  as  600,000,000  at  intervals  of  five  days 
to  a  week.  In  21  cases  he  employed  auto  vaccines  which  he  believed 
more  effective  than  stock  vaccines.  He  states  that  the  pain  was 
diminished  in  20  acute  cases  and  hastened  recovery.  In  some  of  his 
acute  cases  other  joints  became  affected  which  is  not  uncommon  in  the 
ordinary  course  of  the  disease.  He  gave  doses  of  from  25,000,000  to 
100,000,000  in  from  two  to  four  days. 

Hartwell  believes  gonococcal  vaccine' is  useful  in  gonorrheal  arthritis 
in  all  stages  except  in  cases  of  ankylosis.  It  does  not  prevent  metas- 
tases to  other  joints. 

The  consensus  of  opinion  by  the  majority  of  observers  is  that  gonor- 
rheal vaccines  are  more  effective  in  chronic  than  acute  cases. 

RHEUMATIC   ARTHRITIS. 

Many  cases  of  chronic  articular  rheumatism  have  recently  been 
regarded  as  being  of  bacterial  origin,  although  no  specific  organism 
has  been  found.  These  joint  affections  present  local  inflammatory 
symptoms.  They  sometimes  follow  the  development  of  pyorrhea, 
rhinitis  and  especially  tonsillitis.  They  appear  after  scarlet  fever. 
Undoubtedly  bacteria,  that  have  found  their  way  into  the  blood 
stream,  localize  themselves  in  the  joints.  Streptococci  are  often 
obtained  from  the  blood  by  means  of  cultures.  We  know  that  we 
have  postscarlatinal  kidney  infections  showing  streptococci.  Like- 
wise can  the  same  organism  be  demonstrated  in  scarlatinal  arthritis. 
The  same  form  of  bacteria  can  be  cultured  from  secretions  found  in  all 

1  Ann.  Surg.,  November,  1909. 


182  VACCINES 

joints  that  come  to  suppuration.  Streptococci  once  ha^'ing  gained 
access  to  the  blood  current  find  points  of  predilection,  such  as  occur 
in  a  retarded  circulation,  and  almost  stagnant  lymph  fluid  near  joints. 
The  blood  seems  to  have  been  greatly  deprived  of  its  germicide  power, 
the  bacteria  find  favorable  conditions  for  their  propagation  in  their  new- 
locus.  The  opsonic  index,  at  these  points  of  infection,  is  subnormal. 
When  these  arthritic  infections  become  chronic,  the  opsonic  proper- 
ties of  the  blood  stream  becomes  low.  The  circulation  is  more  or  less 
retarded  and  almost  stagnant,  consequently  the  diminished  amount 
of  opsonins  coming  in  contact  with  the  microorganisms  is  not  sufficient 
to  insure  their  destruction.  It  would  seem  that  this  theory  is  con- 
firmed by  the  relief  afi'orded  after  the  use  of  the  constricting  band 
used  in  Bier's  method  where  we  find  that  fresh  blood  with  normal  or 
increased  amount  of  opsonins  as  well  as  fresh  leukocytes  are  driven 
into  the  infected  area,  and  later  driven  into  the  general  circulation 
and  lymph  channels.  The  stagnant  blood  and  lymph  has  been 
replaced  by  fresh  blood  and  lymph  including  new  antibodies. 

Bier's  method  has  recorded  many  clinical  successes  and  deserves 
a  more  extended  trial  than  it  has  generally  received.  It  has  the 
advantage  that  a  bacterial  diagnosis  is  not  necessary. 

Diagnosis. — A  local  bacteriological  diagnosis  is  often  very  difficult 
and,  in  most  instances,  impossible.  We  must  bear  in  mind  that 
many  cases  of  "rheumatic"  and  other  forms  of  arthritis  have  been 
preceded,  and  seem  to  have  had  their  origin  in  an  attack  of  tonsillitis, 
laryngitis,  pharyngitis  or  rhinitis  and  pyorrhea.  It  has,  therefore, 
been  advised  that  cultures  be  made  from  the  nasopharynx  or  nasal 
cavities  and  the  pus  from  the  alveolar  margins  and,  if,  for  instance,  a 
culture  of  pneumococcus  be  obtained  from  the  tonsil,  an  autogenous 
vaccine  be  made  and  adminisfered. 

Before  giving  vaccines  local  infections  must  be  attended  to.  Tonsils 
and  teeth  should  first  be  removed  if  they  appear  to  be  infected. 

Dosage. — If  there  is  an  increased  temperature,  the  dose  would  be 
from  5,000,000  to  25,000,000.  In  non-febrile  cases  small  doses  at 
intervals  of  one  to  two  days  are  given  according  to  the  reaction.  In 
chronic  cases  large  doses  may  be  used  at  intervals  from  three  days 
to  a  week. 

If  vaccines  are  of  any  value,  it  would  seem  that  an  increasing  experi- 
ence, theoretically  at  least,  would  promise  encouraging  result  in 
chronic  non-suppuratlve  or  peri-arthritis,  providing  our  technic  of 
making  a  bacteriological  diagnosis  can  be  perfected.  There  is  danger 
of  overdosage. 

FURUNCLE. 

In'a  case  where  the  infection  begins  in  a  hair  follicle  as  indicated  by 
a  tender,  red,  painful  induration,  its  treatment  depends  on  the  stage 
and  location  in  which  it  is  found.  If  a  pustule,  it  should  be  opened 
by  a  puncture  and  disinfected  and  dressed  with  a  hot  moist  anti- 
septic dressing.     If  there  is  no  evidence  of  suppuration,  one  dose  of 


FURUNCLE  183 

Staphylococcus  pyogenes  aureus  of  stock  vaccine  may  abort  it.  A 
repetition  once  or  twice  at  intervals  of  two  or  three  days  may  be 
necessary.     In  two  or  three  days  the  infected  area  will  begin  to  slough. 

Furunculosis  is  a  condition  where  there  is  a  repetition  of  furuncles. 
In  some  cases  there  is  a  tendency  to  furuncle  formation.  We  some- 
times find  individuals  with  an  oily  pale  skin  that  frequently  develop 
many  furuncles  over  a  long  period  of  time.  They  seem  to  have  a 
predilection  to  harbor  pyogenic  cocci.  In  some  cases  the  individual 
may  inoculate  himself  in  new  localities  by  scratching  often  during 
his  sleeping  hours.  He  scratches  the  primary  furuncles,  infectious 
material  is  caught  under  the  finger  nails  and  transplanted  to  other 
parts  of  the  body.  One  furuncle  is  incised  when  others  develop. 
In  one  of  the  author's  cases  a  full  year  passed  before  the  furuncular 
process  came  to  an  end.  More  than  one  hundred  furuncles  were 
incised.  A  urinalysis  must  not  be  neglected,  especially  in  reference 
to  the  existence  of  glycosuria.  It  is  in  this  field  that  many  excellent 
results  have  been  reported.  It  is  here  where  an  accurate  bacterio- 
logical diagnosis  can  be  made.  The  pus  can  be  easily  obtained  and 
cultured  and  should  be  used  when  practicable.  In  these  cases  stock 
vaccines  seem  to  have  been  useful.  The  vaccines  are  composed  of 
three  or  four  virulent  strains  of  Staphylococcus  aureus.  However, 
when  possible,  autovaccines  should  replace  stock  vaccines  as  soon 
as  they  can  be  made.  The  initial  dose  should  be  100,000,000  to 
150,000,000  and  should  be  repeated  every  third  day.  The  dose  may 
be  gradually  increased  to  300,000,000. 

If  in  twenty-four  hours  the  furuncle  appears  larger  and  more  pain- 
ful and  if  one  or  two  new  ones  develop,  the  dose  should  be  smaller 
because  we  have  to  deal  with  a  negative  phase.  If  in  one  or  two  days 
there  is  improvement  and  the  general  symptoms  are  improved,  the 
correct  dose  has  been  found  and  we  have  a  positive  phase.  New 
furuncles  may  continue  to  develop  for  a  time  but  they  are  less  severe 
and  the  intervals  become  longer  and  they  disappear  more  quickly. 

If  the  case  is  chronic,  and  especially  if  there  are  present  many 
comedones  and  the  pustules  are  on  the  back  and  neck,  the  treatment 
may  require  two  or  three  months  of  time. 

Recurrences  are  not  uncommon  and  must  be  guarded  against  by 
advising  the  patient  to  return  for  fresh  inoculations  as  soon  as  the 
first  evidence  of  return  is  manifest.  The  final  outcome  is  favorable 
if  the  treatment  is  persisted  in.  Since  the  opsonic  index  has  been 
found  impractical  we  are  obliged  to  regulate  dose  and  interval  by 
clinical  observations. 

In  the  treatment  of  these  cases,  we  may  feel  uncertain  as  to  the 
interval  between  doses  and  their  exact  size,  therefore  we  must  be 
guided  by  the  manner  in  which  the  patient  responds.  Many  writers 
of  large  experience,  advise  intervals  of  three  days.  We  should  try  to 
measure  the  dose  so  as  to  insure  a  short  period  of  negative  phase— 
with  its  lowered  resistance — so  as  to  produce  as  long  a  period  of  posi- 
tive phase — a  period  of  increased  resistance.     Each  patient  is  a  law 


184  VACCINES 

unto  himself.  A  safe  rule  is  to  employ  a  small  dose  which  Insures  a 
short  duration  of  the  negative  phase,  which  makes  a  short  positive 
phase.  But  as  we  learn  the  tolerance  of  the  cases,  the  dose  can  be 
increased  and  repeated  in  from  one  to  six  days. 

CARBUNCLE. 

There  are  those  who  have  grown  enthusiastic  over  the  use  of  vac- 
cines in  the  treatment  of  carbuncle.  They  feel  certain  that  in  almost 
every  case  the  process  is  modified  so  that  surgical  intervention  becomes 
simplified  and  can  very  often  be  avoided.  Our  experience  has  taught 
us  that  radical  interference,  that  is,  total  extirpation  of  the  carbuncle, 
is  usually  efficient  and  leads  to  prompt  recovery.  We  have  found  no 
reason  why  prompt  operation  is  still  not  the  best  method.  It  cannot 
be  denied  that  bacteria  and  their  products  have  found  their  way 
into  the  blood  stream.  There  is  a  constant  auto-inoculation.  In  a 
furuncle  the  pus  and  necrotic  material  is  usuallj^  confined  to  a  single 
pocket  which  may  be  evacuated  b>  a  single  puncture  or  incision.  In 
carbuncle  there  is  an  exteiisive  infiltration  of  the  connective  tissues 
with  pu3.  In  carbuncle  there  is  apparently  an  absence  of  a  line  of 
demarcation,  owing  to  the  virulence  of  the  pathogenic  organisms 
and  to  the  liquefying  power  of  the  pus  which  dissolves  the  fat 
and  connective  tissues  as  it  extends.  The  circulation  is  everj-vvhere 
cut  off,  so  that  the  invading  organisms  are  unaffected  by  the  anti- 
bodies carried  in  the  blood  stream.  The  coagulated  lymph  and 
exudation  prevent  an  access  of  blood.  The  process  is  essentially 
an  infiltrating  one,  particularly  when  located  on  the  back  of  the  neck. 
The  columnar  adipose  separate  the  subcutaneous  connective  tissues 
into  numerous  cells  composed  of  connective-tissue  walls.  In  cases  like 
this  it  would  be  unreasonable  to  do  anything  but  radical  surgical  inter- 
ference and  this  is  true  of  all  carbuncles  wherever  located.  After 
free  excision,  a  culture  should  be  made  of  the  pus  to  prepare  an  autog- 
enous vaccine  for  the  purpose  of  antagonizing  the  infectious  sub- 
stance floating  in  the  circulation.  The  operative  procedure  often 
causes  an  exacerbation  of  the  temperature  due  to  auto-inoculation. 
A  moist  antiseptic  dressing,  frequently  changed,  must  be  applied.  A 
free  discharge  from  the  wound  takes  place  owing  to  an  increased  blood 
supph'  to  the  wound.  After  the  effects  following  the  surgical  inter- 
vention have  subsided,  the  injection  of  the  vaccine  may  be  done.  A 
small  dose  of  vaccine  not  exceeding  100,000,000  may  be  employed 
which  may  be  repeated  two  days  later  and  then  every  three  to  four 
days  if  the  temperature  continues  to  fall.  Should  there  still  be  an 
elevated  temperature  after  the  third  day,  especially  if  there  is  no 
drop,  a  smaller  dose  of  50,000,000  should  be  used  and  repeated  daily 
until  we  have  a  normal  temperature  and  then  100,000,000  every 
second  day,  and  at  longer  intervals  until  recovery  is  complete.  The 
wound  must  be  dressed  daily. 

The  urine  must  always  be  examined  especially  for  sugar.     If  the 


ERYSIPELAS  185 

latter  is  present,  the  opsonic  index  is  always  lowered.     The  usual 
dietetic  restrictions  for  glycosuria  must  be  observed. 

When  the  carbuncle  is  on  the  face  the  excision  should  be  short 
with  due  regard  to  the  resulting  scar.  Only  the  necrotic  tissue  should 
be  excised.  Since  carbuncles  in  this  region  are  usually  not  large  and 
the  auto-intoxication  relatively  less,  the  initial  inoculation  need  not 
exceed  25,000,000  Staphylococcus  aureus  and  increased  as  conditions 
seem  to  indicate.  Any  new  pustules  are  to  be  punctured  and  any 
necrotic  margins  are  to  be  excised  with  scissors.  In  five  to  six  days 
the  wound  is  usually  clear  and  granulating. 

EMPYEMA. 

This  condition  is  usually  due  to  the  pneumococcus  and  strepto- 
coccus. Usually  a  free  opening  and  efficient  tubular  drainage  is  quite 
sufficient  for  recovery  without  the  aid  of  other  immunizing  agents. 
There  are  a  few  cases  where,  in  spite  of  thorough  drainage,  an  elevated 
temperature  persists  which  may  be  due  to  defective  immunizing  power ; 
bacterial  vaccines  are  indicated.  In  such  cases  doses  of  pneumococcus 
of  from  10,000,000  to  100,000,000  may  be  given.  The  more  profound 
the  intoxication,  the  smaller  the  dose.  The  dose  is  to  be  repeated 
every  twenty-four  hours  if  it  is  small  and  at  longer  intervals  if  it  is 
larger. 

OSTEOMYELITIS. 

The  administration  of  vaccines  should  always  be  preceded  by 
operative  interference  and  complete  and  free  evacuation  of  the  patho- 
logical products.  Free  drainage  is  of  prime  importance.  In  some 
cases  an  infection  of  the  soft  parts  continues  as  is  indicated  by  a 
persistence  of  local  and  systemic  manifestation  such  as  swelling  pain 
and  increased  temperature.  Vaccines  may  be  indicated  in  these 
cases,  in  doses  ranging  from  100,000,000  to  300,000,000  every  three  to 
five  days.  Usually,  however,  all  systemic  manifestations  disappear 
when  the  infectious  material  has  a  free  exit  and  when  the  improve- 
ment is  prompt,  as  it  usually  is,  vaccines  are  superfluous. 

ERYSIPELAS. 

The  most  common  seat  of  erysipelas  as  met  with  in  general  practice, 
is  in  the  face.  These  attacks  are  usually  self-limited  and  are  of  such 
short  duration  that  vaccines  are  not  indicated.  It  is  only  in  the 
spreading  tjq^e  in  which  we  may  expect  some  assistance  from  vaccines. 
Autogenous  vaccines  should  be  used  when  they  can  be  obtained,  but 
the  more  common  practice  has  been  the  use  of  stock  vaccines.  During 
the  active  stage  small  doses  are  indicated.  We  must  regulate  our 
dosage  as  in  septicemia.  The  initial  dose  should  not  be  over  1,000,000 
once  daily  and  increased  slowly  not  to  exceed  25,000,000.  The 
usual  local  treatment  must  not  be  neglected.     Observations  thus  far 


186  VACCINES 

have  not  enabled  us  to  speak  with  certainty  as  to  the  actual  benefits 
derived  from  the  use  of  vaccines  in  erysipelas,  but  their  use  must  not 
be  entirely  ignored. 

VARICOSE  ULCERS. 

Staphylococci  are  often  found  in  these  ulcers.  It  has  been  claimed 
that  autogenous  vaccines  of  these  organisms  are  useful  in  leg  ulcers. 
It  is  asserted  that  the  use  of  stock  vaccines  has  cleared  up  the  ulcer 
in  a  few  days.  The  wound  was  dressed  daily  with  Wright  solution 
consisting  of  0.5  per  cent,  of  citrate  sodium  and  2  per  cent,  of  sodium 
chloride.  However,  vaccines  must  be  looked  upon  as  only  an  adjunct 
to  other  measures  which  are  indicated.  We  must  take  into  account 
and  treat  the  venous  varicosities  which  exist  in  most  cases,  nor  must 
we  neglect  antiseptic  and  aseptic  precautions  so  essential  in  the 
treatment  of  all  wounds. 


BLOOD  TRANSFUSION. 


NELSON  MORTIMER  PERCY,  M.D.,  F.A.C.S. 

While  the  transfusion  of  blood  as  a  practical  procedure  is  a  com- 
paratively new  acquisition  in  the  field  of  surgery,  the  idea  of  using 
blood  as  a  therapeutic  measure  dates  back  to  the  fifteenth  century. 
In  1660,  Lower^  in  his  experiments  made  successful  transfusions  in 
various  animals.  Following  this,  the  blood  of  animals,  usually  from 
sheep,  was  given  to  humans  with  apparent  benefit  in  an  occasional 
instance.  It  soon  became  evident  that  the  introduction  of  the  blood 
of  lower  animals  into  man  was  an  unsatisfactory  and  dangerous  pro- 
cedure and  the  practice  fell  into  disuse.  It  is  probable  that  many  of 
the  deaths  were  due  to  hemolj'sis  or  anaphylaxis. 

Animal  transfusion  was  then  abandoned  for  human  transfusion,  and 
during  the  past  century  many  experiments  were  made  on  the  direct 
transfusion  of  blood  from  one  person  to  another.  Transfusion  of  human 
blood,  as  practised  during  this  period,  was  so  unsatisfactory  and 
dangerous  that  this  procedure  also  fell  into  great  disfavor. 

The  failure  of  these  early  transfusions  was  probably  due  to  two 
main  factors:  that  the  attempt  was  made  before  the  days  of  aseptic 
technic;  and  because  of  the  lack  of  knowledge  of  the  incompatibility 
of  various  bloods  with  each  other.  In  1870,  Landois^  opened  the  way 
for  the  safe  transfusion  of  blood  when  he  discovered  that  the  blood  of 
one  individual  was  not  always  compatible  with  that  of  another.  While 
he  did  not  explain  this  phenomenon,  nor  offer  any  method  of  deter- 
mining the  incompatibilities  of  various  bloods,  he  showed  that  the 
serum  of  one  animal  might  dissolve  the  red  corpuscles  of  another. 

It  remained  for  jNIoss^  to  publish  in  1910  his  studies  of  iso-agglutinins 
and  isohemolysins.  He  showed  that  the  blood  from  two  individuals 
may  not  mix  well  because  of  the  fact  that  the  red  corpuscles  of  one  or 
of  each  may  be  agglutinated  by  the  serum  of  the  other,  and  that^the 
corpuscles  agglutinated  in  this  way  may  be  hemolyzed  as  well.  He 
further  showed  that  all  individuals  soon  after  birth  may  be  grouped 
into  fom-  distinct  classes,  depending  upon  the  ability  of  their  serum  to 
agglutinate  the  red  corpuscles  of  members  of  the  other  groups,  and  on 
the  susceptibility  of  their  corpuscles  being  agglutinated  by  the  serum 
of  members  of  other  groups.  The  principles  established  by  Moss  really 
opened  the  way  to  the  practical  work  of  using  blood  as  a  therapeutic 
measure  in  patients  suffering  from  various  conditions. 

'  Philosophical  Transactions  and  Collections  of  Medical  and  Philological  Papers, 
John  Lawthrop,  1731. 

^  Die  Transfusion  des  Blutes,  1875. 

3  Bull.  Johns  Hopkins  Hosp.,  March,  1910. 

( 187  ) 


188  BLOOD  TRANSFUSION 

Recently,  because  of  the  increased  interest  in  the  possibilities  of 
transfusion,  many  methods  of  transfusing  the  blood  have  been  devised, 
making  transfusion  practical.  With  the  development  of  these  various 
methods,  the  various  factors  responsible  for  the  untoward  symptoms 
following  transfusion  have  been  eliminated,  and  as  a  result,  transfusion 
of  blood  in  the  hands  of  an  experienced  operator  can  be  done  with 
very  little  or  no  danger  to  either  the  donor  or  recipient  of  the  blood. 

Indications  for  Blood  Transfusion. — Blood  transfusion  is  used  as  a 
siugical  therapeutic  measure  whene^■er  all  or  part  of  the  elements  of 
blood  tissue  are  needed  and  cannot  be  obtained  in  sufficient  amounts 
from  the  hematopoietic  organs  of  the  individual.  These  elements 
may  be  required:  (a)  To  replace  loss  of  whole  blood,  (b)  to  increase 
coagulability,  and  (c)  to  stimulate  resistance  to  infection  and  various 
other  toxic  processes. 

It  is  a  well-known  fact  that  the  administration  of  normal  salt  solution 
or  the  various  modifications  of  Ringer's  solution,  either  intravenously 
or  subcutaneously,  has  a  marked  beneficial  eft'ect  in  certain  conditions 
where  more  fluid  is  needed  that  cannot  be  ingested  by  any  otlif  r  means. 
By  this  form  of  treatment,  then,  one  can  hope  only  to  give  an  increased 
amount  of  body  fluid.  On  the  other  hand,  by  the  transfusion  of  whole 
blood,  one  injects  a  living  tissue  which  has  functions  inherent  on  its 
o'wn  constituents,  and  which  thereby  serves  an  entirely  different 
purpose. 

When  this  treatment  was  first  exploited  it  was  used,  as  is  usually  the 
case,  in  many  conditions  in  which  it  had  no  effect,  or  even  did  harm. 
At  present,  however,  we  know  that  in  many  instances  the  addition  of 
fresh,  living,  whole  blood  to  a  patient  from  another  individual  may  save 
a  life,  cure  the  pathological  condition  present,  or  at  least,  greatly 
improve  the  patient. 

The  indications  which,  from  our  experience,  are  those  best  suited 
to  this  form  of  treatment  will  now  be  given  in  more  detail. 

Hemorrhage. — Severe  hemorrhage  is,  of  course,  a  specific  indication 
for  blood  transfusion,  and  it  is  in  these  cases  that  the  most  brilliant 
results  have  been  experienced.  In  postoperative,  postpartum,  and 
gastric  ulcer  bleeding  this  method  has  been  advocated  and  used  with 
success  for  a  number  of  years.  However,  one  should  bear  in  mind  the 
fact  that  Nature  attempts  to  control  the  hemorrhage  in  two  ways: 
(a)  by  producing  a  fall  in  blood-pressure  and,  (6)  by  attempting  to 
cause  a  clot  at  the  end  of  the  bleeding  vessel.  If  additional  blood  be 
added  in  sufficient  quantity  to  increase  the  blood-pressure  momen- 
tarily a  clot  may  in  this  way  be  dislodged  and  the  hemorrhage  increased. 
Where  it  is  possible  to  check  the  hemorrhage  by  mechanical  means, 
such  as  by  open  operation  in  gastric  ulcer  or  in  ectopic  gestation,  or  by 
packing  in  postpartimi  bleeding,  blood  transfusion,  both  before  and 
after  such  procedure,  tides  the  patient  over  an  otherwise  frequently 
fatal  period.  It  is  in  the  severe  hemorrhages  that  large  amounts,  from 
600  c.c.  to  1500  c.c,  are  given.  The  transfusion  of  amounts  less  than 
600  c.c.  has  not,  in  our  experience,  been  suflBcient  to  control  such  cases. 


OBSCURE  HEMORRHAGES  189 

We  have  also  noted  that  amounts  greater  than  900  or  1000  c.c.  do  not 
produce  more  satisfactory  effects  than  the  giving  of  600  to  800  c.c, 
and  repeating  one  or  more  times.  This  amount  seems  to  be  best 
suited  both  to  replace  the  lost  blood  and  to  favor  clotting  at  the 
bleeding  point. 

Obscure  Hemorrhages. — Occasionally  one  encounters  a  patient  in 
whom,  following  a  surgical  operation,  without  any  apparent  cause 
a  secondary  hemorrhage  occurs  from  the  wound  after  a  period  of  from 
one  to  three  weeks,  and  will  keep  recurring  in  spite  of  all  the  ordinary 
medicinal  and  surgical  means  at  one's  command.  Many  of  these  cases 
in  the  past  have  terminated  fatally.  These  cases  usually  do  not  give  a 
history  of  hemophilia,  and,  so  far  as  I  know,  no  reasonable  explaniation 
as  to  the  cause  has  ever  been  given. 

Ilhistrative  Case. — ^A  woman,  aged  forty-eight  years,  in  apparent 
good  health,  except  for  usual  symptoms  from  a  lacerated  perineum. 
The  patient  was  taken  to  the  hospital  and  a  perineorrhaphy  performed. 
A  good  immediate  recovery  followed  and  the  patient  returned  home  at 
the  end  of  two  weeks.  A  few  days  later,  which  was  eighteen  days  after 
the  operation,  a  severe  hemorrhage  occurred  from  the  perineum.  The 
hemorrhage  was  finally  controlled  by  enlarging  the  opening  in  the 
perineum  from  which  the  blood  was  coming  and  packing  the  area  with 
gauze.  Three  days  later,  when  the  packing  was  removed,  a  lively 
hemorrhage  followed  immediately.  Packing  was  replaced  and  as  soon 
as  could  be  arranged  the  perineum  was  reopened  and  sutured.  At  this 
time  the  patient  was  given  some  coagulose.  One  week  later  the 
hemorrhage  recurred.  The  perineum  was  again  partially  opened  and 
packed  with  gauze.  During  the  following  two  weeks  the  packing  was 
changed  every  three  or  four  days  and  each  time  active  hemorrhage 
occurred.  During  this  period  coagulose  was  used  and  also  several 
doses  of  horse  serum.  Calcium  chloride  was  also  given  and  the  patient 
placed  on  a  gelatin,  white  of  egg  and  milk  diet.  I  saw  the  patient  seven 
weeks  after  the  operation,  at  which  time  she  had  a  pulse  of  140,  was 
extremely  weak;  had  no  appetite;  temperature  subnormal;  hemo- 
globin 20  per  cent.;  red  count  1,200,000;  white  count  8000.  A  donor 
was  immediately  selected  and  the  patient  was  taken  to  the  operating 
room.  Upon  removing  the  perineal  packing  a  marked  bleeding  occurred, 
the  blood  being  very  watery  like.  The  principal  part  of  the  bleeding 
was  controlled  by  suturing  the  perineum,  but  in  spite  of  the  fact  that 
round,  non-cutting  needles  were  used,  slight  bleeding  came  from  around 
each  suture  and  it  was  impossible  to  control  the  oozing.  As  soon  as  the 
perineal  wound  was  rendered  as  dry  as  possible  a  transfusion  of  900 
c.c.  of  blood  was  given.  Within  ten  minutes  from  this  time  the  perineal 
wound  was  perfectly  dry  and  the  pulse  had  dropped  from  150  to  110. 
Five  days  later  a  second  transfusion  of  700  c.c.  was  given.  There  was 
absolutely  no  bleeding  from  the  time  of  the  first  transfusion,  the  wound 
healed  primarily,  the  patient  made  a  rapid  convalescence  and  left  the 
hospital  at  the  end  of  three  weeks,  with  a  red  count  of  over  4,000,000, 
and  has  remained  in  good  health.    No  doubt  this  case  would  have 


190  BLOOD  TRANSFUSION 

terminated  fatally,  in  spite  of  anything  that  could  have  been  done,  had 
not  the  blood  transfusion  been  given. 

Hemorrhages  Complicating  Infectious  Diseases. — Troublesome  hemor- 
rhanges  occurring  as  a  complication  of  one  of  the  infectious  diseases 
can  usually  be  relieved  by  blood  transfusion. 

lUustrative  Case. — A  boy,  aged  seven  years,  with  apparent  good 
health,  developed  rather  typical  signs  and  symptoms  of  measles, 
except  that  the  accompanying  rash  disappeared  in  about  twenty-four 
hours.  One  week  later  he  began  to  bleed  from  mouth,  stomach  and 
bowels.  Blood  was  also  present  in  the  urine.  The  bleeding  persisted 
and  at  the  end  of  the  second  week  numerous  purpiu'ic  areas  appeared  on 
the  skin.  At  this  time  his  condition  was  grave;  pulse,  KM)  per  minute, 
weak;  hemoglobin,  15  per  cent.;  red  count,  1,200,000;  hemorrhages 
persisting.  Transfusion  of  600  c.c.  of  blood  gave  instant  relief.  The 
hemorrhage  ceased  within  five  minutes  and  the  patient  made  a  rapid 
and  complete  recovery. 

Typhoid  Fever — Early  in  transfusion  work,  hemorrhage  complicating 
typhoid  fever  was  not  considered  as  a  condition  in  which  blood  trans- 
fusion was  indicated.  Recently,  however,  a  number  of  typhoid  cases 
complicated  with  hemorrhage  have  been  transfused,  in  which  the 
hemorrhage  stopped  immediately  after  transfusion  of  whole  blood, 
following  which  the  patients  went  on  to  complete  recovery. 

Icterus. — Patients  with  obstruction  of  the  common  duct  with  long- 
standing jaundice  are  extremely  hazardous  surgical  risks.  These 
patients  usually  do  well  for  a  couple  of  days  following  an  operation, 
then  have  some  hemorrhage  from  the  wound,  not  severe,  however, 
and  then  gradually  weaken  and  just  slip  away  without  any  special 
symptoms  and  without  any  apparent  cause.  Blood  transfusion  is  indi- 
cated in  these  cases  if  a  surgical  operation  is  performed  and  will  often 
tide  the  patient  over  an  otherwise  hopeless  period.  During  the  past 
two  years  the  author  has  systematically  transfused  all  cases  of  marked 
persistent  icterus  at  the  time  of  the  operation,  none  of  which  has  died 
from  cholemia,  while  from  past  experience  it  is  evident  some  of  these 
cases  would  have  terminated  fatally  without  the  transfusion. 

Anemia  Complicating  Pregnancy. — Occasionally  one  encounters  a  rare 
t;^"pe  of  anemia  occurring  as  a  complication  of  gestation,  which  simulate 
very  much  a  pernicious  anemia.  In  most  instances  the  anemia  improves 
immediately  following  delivery  without  any  special  treatment.  Occas- 
ionally the  anemia  continues  to  progress  after  delivery.  In  such 
instances  blood  transfusion  is  indicated  and  is  followed  by  brilliant 
results. 

Secondary  Anemia. — In  cases  of  persistent  oozing  of  blood  in  small 
amounts  from  any  part  of  the  body,  with  a  consequent  secondary  drop 
in  the  blood  picture  or  in  Avhich  there  is  a  constant  destruction  of  cir- 
culatory elements  from  an  infective  or  toxic  process,  blood  transfusion 
has  been  found  of  great  value.  Amounts  of  500  to  700  c.c,  repeated 
at  every  six  to  ten  days,  do  as  much  good  as  when  larger  amoimts  are 
used.    The  transfusions  should  be  repeated  until  the  bood  picture  has 


ACUTE  SURGICAL  SHOCK  191 

permanently  nnproved.  Conditions  included  in  this  class  are:  intes- 
tinal bleeding,  epistaxis,  pulmonary  hemorrhage,  hemorrhoids,  and 
hematuria  from  various  causes. 

Hemophilia. — In  this  condition  there  is  a  greatly  delayed  coagidation 
time,  so  that  small  abrasions  may  allow  of  severe  and  persistent 
hemorrhage.  Frequently,  the  blood  of  these  patients  will  fail  to  clot 
in  an  hour  or  more.  Here,  blood  transfusion  may  be  employed  during 
the  active  stage  of  bleeding,  because  enough  prothrombin  will  in  this 
way  be  supplied  to  produce  the  necessary  clotting.  At  the  same  time 
the  lost  blood  is  being  replaced  by  new  blood  elements.  For  this 
reason  whole  blood  is  a  better  medium  than  blood  serum  alone.  E^'en 
after  the  bleeding  has  stopped,  it  is  advisable  to  give  occasional 
prophylactic  transfusions  of  500  to  700  c.c.  of  whole  blood  in  order  to 
supply  the  demand  for  prothrombin. 

Hemorrhagic  Diseases  of  the  Newborn. — In  these  conditions  the 
treatment  by  blood  transfusion  has  been  successful  in  a  large  niunber  of 
instances  and  the  lives  of  many  infants  have  been  saved.  There  is,  of 
course,  great  difficulty  in  using  the  veins  of  infants,  and  for  this 
reason,  Helmholz  has  recently  carried  out  a  method  which  has  been 
used  in  many  cases.  He  punctures  the  anterior  fontanelle  in  the  mid- 
line and  so  enters  the  superior  longitudinal  sinus,  which  is  a  relatively 
large  vessel  in  infants. 

Toxemia. — In  toxemia  from  any  cause,  or  where  there  is  a  condition 
of  general  debility  due  to  disease  or  metabolic  derangement,  blood 
transfusion  has  proved  of  marked  benefit. 

Septicemia. — We  have  seen  several  cases  of  severe  septicemia  fol- 
lowing pelvic  cellulitis,  postpartum  infection  and  peritonitis  in  which 
the  process  had  gone  on  to  a  practically  hopeless  stage  and  in  which 
blood  transfusion  was  resorted  to  as  a  last  measure.  Several  of  these 
cases  were  definitely  improved  and  a  few  of  them  recovered.  It  would 
seem  that  in  such  instances  the  resistance  of  the  patient  was  just 
insufficient  to  combat  the  disease.  By  the  administration  of  whole 
blood,  new  antibodies  and  fresh  red  cells  were  furnished  which  became 
the  added  stimulus  necessary  to  give  the  resisting  process  the  upper 
hand.  We  therefore  believe  septicemia,  bacteremia  and  toxemia  to  be 
faA'orable  indications  for  blood  transfusion. 

Banti's  Disease  and  Hemolytic  Icterus. — These  conditions  are  essen- 
tially surgical  and  blood  transfusion  is  not  indicated  where  the  blood 
picture  is  not  materially  lowered.  When,  however,  the  red  cell  count 
is  lower  than  2,500,000  or  there  are  persistent  hemorrhages,  blood  trans- 
fusion should  be  resorted  to  as  a  preliminary  treatment  to  splenectomy. 
The  latter  procedure  offers  the  only  hope  of  a  permanent  abatement, 
but  the  previous  administration  of  new  blood  usually  allows  of  a 
better  surgical  risk.  In  fact,  blood  transfusion  has  been  sho^m  by 
many  different  workers  to  be  of  benefit,  at  least  temporarily,  in 
practically  every  blood  disease. 

Acute  Surgical  Shock.— In  cases  in  which  it  is  known  that  a  severe 
operation  is  necessary,  such  as  in  carcinoma  of  the  intestine  and  in  which 


192  BLOOD  TRANSFUSION 

there  is  a  marked  cachexia  and  general  weakness,  these  cases  can  often 
be  improved  in  a  general  way  to  such  an  extent  that  the  danger  of 
surgical  shock  is  markedly  decreased.  One,  two  or  three  blood  trans- 
fusions of  500  to  700  c.c,  given  a  week  apart  before  the  operation,  will 
sometimes  make  an  otherwise  hopeless  condition  a  fairly  good  surgical 
risk.  Likewise,  after  a  long,  tedious,  severe  operation,  the  adminis- 
tration of  a  pint  of  whole  blood  just  after  the  operation  is  finished  and 
while  the  last  stitches  are  being  applied  will  make  a  change  that  is  often 
quite  remarkable.  A  marked  improvement  of  the  general  condition  of 
the  patient  is  evidenced  by  a  better  surface  color,  a  strengthening  of 
the  heart  action  and  a  drop  in  the  pulse  rate  of  30  to  50  beats  per 
minute. 

lUuminating  Gas  Poisoning. — In  illuminating  gas  poisoning  there  is  a 
permanent  destruction  of  the  hemoglobin  in  the  red  cells  so  far  as  the 
oxygen-carbondioxide  carrying  capacity  is  concerned.  In  such  cases 
the  transfusion  of  whole  blood,  thus  adding  enormous  numbers  of  red 
cells  and  fresh  hemoglobin,  has  in  several  instances  saved  the  lives  of 
individuals  that  would  otherwise  probably  have  gone  on  to  a  fatal 
termination. 

Pernicious  Anemia. — The  transfusion  of  blood  in  pernicious  anemia 
has  recently  received  a  great  deal  of  attention  and  has  been  advocated 
by  some  as  the  sole  means  of  treating  this  form  of  anemia. 

In  view  of  the  fact  that  pernicious  anemia  is,  in  all  probability,  a 
disease  of  infectious  origin  and  that  the  spleen  has  abnormal  hemol}i:ic 
action  on  the  blood  elements  with  a  late  bone-marrow  exhaustion,  the 
writer  is  convinced  that  the  rational  treatment  consists  of  three  main 
factors,  viz.:  (a)  massive  stepladder  transfusions  of  whole  blood,  (b) 
splenectomy  and  (r)  removal  of  all  possible  sources  of  infection. 

Each  of  these  steps  plays  an  important  part  in  the  treatment.  The 
repeated  blood  transfusions  nourish  and  stimulate  the  bone-marrow 
to  action  and  nelp  to  restore  the  secondary  changes  in  the  various 
organs;  the  splenectomy  unquestionaby  reduces  the  amount  of  blood 
destruction,  and  the  removal  of  the  various  foci  of  infection  will 
relie\'e  the  patient  of  a  chronic  toxemia  and  possibly  of  an  etiological 
factor  of  the  disease. 

The  emploATnent  of  blood  transfusion  will  result  in  marked  tempo- 
rary improvement  in  the  vast  majority  of  cases.  Our  experience  has 
been  that  while  the  blood  pictures  will  improve  immediately  in  prac- 
tically every  case,  and  that  in  some  early  cases  a  prompt  and  marked 
remission  will  take  place  and  may  persist  for  a  period  of  several  months, 
on  the  other  hand,  in  the  late  cases,  the  improvement  in  the  blood 
picture  from  transfusion  alone  is  very  transitory,  as  the  blood  will 
begin  to  decline  within  a  period  of  two  or  three  weeks  unless  trans- 
fusion is  repeated. 

In  all  of  our  cases  except  two  that  have  come  to  operation,  trans- 
fusion has  been  used  as  a  preliminary  measure  before  operation.  It 
has  also  been  employed  in  several  extreme  cases  simply  as  a  measure  of 
prolonging  life  for  a  short  time.    From  our  experience  it  would  seem 


PERNICIOUS  ANEMIA  193 

that  practically  every  ease  of  pernicious  anemia,  even  those  in  an 
extreme  condition,  can  be  temporarily  improved.  Ottenberg  and 
Liberman,^  however,  found  that  in  25  cases  of  pernicious  anemia 
treated  by  blood  transfusion  only  14  showed,  for  a  time,  progressive 
improvement.  Tn  11  cases  transfusion  was  of  no  avail.  From  this  they 
conclude  that  blood  transfusion  induces  a  remission  in  about  one-half 
of  the  patients,  and  that  if  improvement  does  not  follow  the  first 
transfusion,  another  donor  should  be  selected  and  transfusion  repeated. 

During  the  past  five  years  the  reader  has  transfused  ninety 
patients  suffering  from  pernicious  anemia,  including  sixty-six  that 
have  come  to  operation,  and  a  marked  improvement,  both  in  the  blood 
picture  and  clinical  condition  of  the  patient,  has  resulted  in  all  but  one 
case.  This  patient  was  brought  to  the  hospital  in  a  comatose  condition, 
received  one  blood  transfusion,  with  practically  no  change  in  condition, 
and  death  resulted  ten  days  later. 

The  immediate  effects  of  transfusion  are  usually  quite  striking.  The 
red  blood  count  is  increased  (often  doubling  immediately  when  the 
count  is  very  low) ,  the  hemoglobin  percentage  rises  and  the  number  of 
platelets  is  increased.  The  blast  cells  usually  become  more  numerous, 
and  occasionally  Howell's  particles  will  appear  in  the  blood,  thus  indi- 
cating a  stimulation  of  the  bone-marrow. 

Robertson^  studied  4  cases  of  primary  pernicious  anemia  treated  by 
blood  transfusion,  with  a  view  of  determining  the  effect  of  the  treat- 
ment in  the  excessive  output  of  urobilin.  Three  of  the  four  patients 
gave  evidence  of  a  resulting  bone-marrow  stimulation  and  at  the  same 
time  showed  a  temporary  increase  of  urobilin  excretion.  In  one 
instance  there  was  no  change  in  the  output  of  urobilin. 

After  transfusion  the  patients  immediately,  as  a  rule,  volunteer  the 
information  that  they  feel  stimulated  and  much  "stronger  than  they 
felt  before."  A  few  hours  later  they  become  ravenously  hungry,  while 
previously  food  often  had  to  be  forced  upon  them.  This  hunger  and 
relish  of  their  food  persists  even  after  the  red  blood  count  begins  to 
fall,  which  usually  takes  place  about  ten  days  or  two  weeks  later. 
With  the  improvement  in  appetite  the  mental  symptoms  grow  better, 
the  insomnia  is  relieved  and  the  glossitis  clears  up.  There  is  no  doubt 
that  the  transfusion  of  large  masses  of  whole  blood  accomplishes  more 
than  the  mere  mechanical  addition  of  so  much  blood.  It  seems  that  it 
actually  exerts  either  a  curbing  influence  on  the  hyperactive  spleen  or 
a  stimulating  action  on  the  bone-marrow,  since  the  blood  picture 
continues  to  improve  for  several  days  after  transfusion.  This  may  be 
due  to  the  fact  that  the  blood-forming  organs  are  not  only  overworked, 
but  are  also  undernourished.  Furthermore,  multiple  blood  transfusions 
supply  protective  antibodies  and  assist  the  patient  in  getting  rid  of  the 
secondary  changes  which  have  taken  place  in  the  various  organs. 
During  the  period  when  the  individual  is  being  prepared  for  operation 
by  multiple  blood  transfusions,  he  should  be  treated  to  eradicate  any 

1  Jour.  Am.  Med.  Assn.,  1915,  Ixiv,  2163. 

2  Arch.  Int.  Med.,  1915,  xvi,  429. 

VOL.  1—13 


194  BLOOD   TRAXSFUSION 

self-evident   infection,   such   as   infected   teeth   or  tonsils,   pyorrhea 
alveolaris,  etc. 

The  patients  begin  to  improve  immediately  after  the  first  trans- 
fusion and  continue  to  improve  with  each  subsequent  transfusion  until 
they  are  good  surgical  risks,  and  splenectomy  can  be  done  without 
greater  shock  than  would  be  produced  in  any  other  patient  by  an  oper- 
ation of  the  same  magnitude.  At  the  time  of  operation  a  transfusion 
of  from  (300  to  1000  c.c.  of  blood  should  be  given  immediately  at  the 
close  of  the  operation. 

By  combining  the  blood  transfusions  with  splenectomy  and  eradi- 
cation of  all  foci  of  infection  our  results  in  pernicious  anemia  have  been 
very  encouraging. 

Preliminary  Examination. — The  most  important  part  of  transfusion 
is  the  selection  of  a  healthy  donor,  and  the  making  of  hemohtic  and 
agglutination  tests  between  the  two  bloods.  In  addition  to  this,  it  is 
well  to  determine  as  nearly  as  possible  the  exact  condition  of  the  blood 
before  transfusion  in  both  the  donor  and  the  recipient.  This  exami- 
nation should  consist  of  a  red  and  white  cell  count,  hemoglobin  per- 
centage, coagulation  time,  a  differential  count,  also  noting  the  character 
of  the  various  t^•pes  of  corpuscles. 

Donor.^In  selecting  a  donor  it  is  important,  in  addition  to  making 
hemolytic  and  agglutination  tests,  that  a  careful  history  be  obtained 
from  the  donor,  and  a  complete  physical  examination  made,  including 
a  Wassermann  test.  Donors  should  not  be  chosen  from  persons  giving 
a  history  of  recent  attacks  of  t^-phoid  fever,  pneumonia,  diphtheria, 
tonsillitis,  malaria  or  influenza,  or  from  persons  suffering  from  tuber- 
culosis, chronic  arthritis,  rheumatism  or  where  there  is  a  history  of 
hemophilia. 

Hemolytic  and  Agglutination  Tests. — A  hemolytic  or  agglutination 
test  of  each  blood  upon  the  other  should  always  be  made  before  trans- 
fusion, because  it  has  been  found  that  in  a  considerable  percentage  of 
cases  there  is  a  tendency  of  the  serum  of  one  blood  to  cause  a  disinte- 
gration of  the  red  cells  of  another  even  when  the  latter  be  a  near 
relative.  ^Yhile  the  bloods  from  members  of  the  same  family  are  more 
liable  to  be  compatible  with  each  other  than  aliens'  blood,  still  it  is  never 
safe  to  use  even  a  close  relative  as  a  donor  without  making  a  hemolytic 
test  between  the  bloods  to  be  mixed. 

Hemolysis  Test.— Ten  cubic  centimeters  of  blood  are  collected  from  a 
vein  of  the  donor  (D.),  5  c.c.  of  which  is  placed  in  a  dry  centrifuge  tube 
and  allowed  to  clot  and  the  remaining  5  c.c.  mixed  thoroughly  with 
10  c.c.  of  a  0.5  per  cent,  sodium  citrate  in  normal  salt  solution.  The 
latter  solution  preserves  the  red  cells  and  pre^•ents  clotting.  Both 
tubes  are  now  rapidly  centrifuged.  In  one  tube  the  clotted  blood  will 
separate,  leaving  a  clear  serum  as  an  upper  layer;  1  c.c.  of  this  serum 
is  then  added  to  9  c.c.  of  normal  salt  solution  in  a  test-tube  and  labelled 
10  per  cent,  solution  of  D.'s  serum.  The  other  centrifuge  tube  now 
contains  a  compact  layer  of  red  cells  in  the  bottom  and  an  upper  clear 
laver  of  mixed  sermn  and  salt  solution.    This  upper  layer  is  carefully 


AGGLUTINATION  TEST  195 

poured  off  and  the  same  amount  of  fresh  normal  salt  solution  is  added, 
with  a  pipette,  so  as  to  thoroughly  mix  the  cells.  The  tube  is  again 
centrifuged.  This  procedure  is  repeated  ten  or  twelve  times  in  order 
to  thoroughly  wash  the  red  corpuscles  free  of  serimi.  Finally,  1  c.c. 
of  the  corpuscles  is  mixed  with  9  c.c.  of  normal  salt  solution  in  a  test 
tube  and  labelled  10  per  cent,  suspension  of  D.'s  corpuscles.  Ten  cubic 
centimeters  of  blood  are  collected  in  the  same  way  from  the  recipient 
(R.)  and  a  10  per  cent,  solution  of  serum  and  a  10  per  cent,  suspension 
of  cells  are  prepared  as  above  and  placed  in  separate  test-tubes.  These 
four  10  per  cent,  solutions  and  suspensions  are  used  in  setting  up  the 
test. 

In  a  clean  test-tube  1  c.c.  of  D.'s  serum  is  mixed  with  1  c.c.  of  D.'s 
corpuscles.  In  a  second  tube  1  c.c.  of  R.'s  serum  is  mixed  with  1  c.c.  of 
R.'s  corpuscles.  These  two  tubes  are  used  as  controls.  In  a  third  tube 
1  c.c.  of  R.'s  serum  is  mixed  with  1  c.c.  of  D.'s  corpuscles  and  in  another 
tube  1  c.c.  of  R.'s  corpuscles  is  mixed  with  1  c.c.  of  D.'s  serum.  These 
four  tubes  are  placed  in  the  incubator  at  37.5°  C.  for  two  hours,  diu-ing 
which  interval  the  tubes  are  shaken  several  times.  They  are  then 
placed  in  the  icebox  for  twelve  hours  and  shaken  occasionally  to  ensure 
mixing.  If  the  blood  cells  remain  as  a  layer  in  the  bottom  of  the  te5t- 
tubes  and  there  is  a  clear,  nearly  colorless  fluid  above,  or  if  the  tube, 
when  shaken,  be  quite  cloudy  and  not  transparent  there  has  been  no 
hemolysis.  If  there  are  no  red  cells  present  as  a  layer,  or  if  the  shaken 
tube  is  clear  and  wine-colored,  there  has  been  hemolysis  of  the  red  cells. 
The  two  control  tubes  should  show  no  hemolysis.  If  they  do,  there  has 
been  an  error  in  technic. 

Agglutination  Test.- — During  the  past  year  the  writer  has  been  deter- 
mining the  hemoh-tic  action  of  the  blood  by  the  ]\Ioss  method,  the 
technic  of  which  has  been  modified  by  Brem.^  This  method  is  based  on 
the  principle  that  before  the  serimi  of  one  blood  will  cause  a  hemolysis 
of  the  corpuscles  of  another  it  will  first,  or  simultaneously,  cause  an 
agglutination  of  the  corpuscles.  The  reverse,  that  all  cases  that  show 
agglutination  will  also  show  hemolysis,  is  not  necessarily  true,  only 
occurring  in  about  20  per  cent,  of  cases.  Adopting  this  principle,  all 
bloods  are  classified  according  to  the  agglutinative  properties  of  their 
elements  into  one  of  foiu  groups.  In  selecting  a  donor  it  is  always 
advisable  to  have  a  donor  whose  blood  belongs  to  the  same  group  as 
that  of  the  patient.  If  this  is  impossible  the  donor's  blood  should 
belong  to  a  group  whose  corpuscles  are  not  agglutinated  by  the  serimi 
of  the  patient.  The  bloods  of  Group  IV  answer  this  requirement  for 
all  the  other  groups,  as  its  corpuscles  are  not  agglutinated  by  the  serum 
of  any  group.  Fortunately,  group  IV  is  the  most  common  group,  ]\Ioss 
having  found  that  43  per  cent,  of  all  individuals  belong  to  this  group. 

IMoss  found  that  all  bloods,  whether  normal  or  pathological,  could  be 
classified  into  four  groups  by  agglutination  tests  of  the  serums  against 
the  corpuscles.    He  found  the  groups  to  be  as  follows : 

iJour.  Am.  Med.  Assn.,  July  15,  1916. 


196 


BLOOD   TRANSFUSION 


Group  I.  10  per  cent.  Serum  does  not  agglutinate  corpuscles  of 
any  group.    Corpuscles  are  agglutinated  by  serum  of  II,  III  and  IV. 

Group  II.  40  per  cent.  Serum  agglutinates  corpuscles  of  groups 
I  and  III,  not  IV.  Corpuscles  agglutinated  by  serum  of  III  and  IV, 
not  I. 

Group  III.  7  per  cent.  Sermn  agglutinates  corpuscles  of  groups  I 
and  II,  not  IV.    Corpuscles  agglutinated  by  serum  of  II  and  IV,  not  I. 

Group  IV.  43  per  cent.  Serum  agglutinates  corpuscles  of  groups 
I,  II  and  III.    Corpuscles  are  not  agglutinated  by  any  serum. 

The  serum  of  one  group  will  not  agglutinate  the  corpuscles  of  blood 
belonging  to  the  same  group. 

Corpuscles 


Group 
I 

Group 
II 

Group 
III 

Group     j 
IV 

0 

0 

0 

0 

Group 
I 

+ 

0 

+ 

0 

Group 
II 

+ 

+ 

0 

0 

Group 
III 

+ 

+ 

+ 

0 

Group 
IV 

Moss  chart,  showing  the  reaction  of  the  various  groups  against  each  other. 

In  grouping,  the  unknown  blood  should  be  tested  with  a  blood  whose 
group  is  kno^\'n.  This  "standard"  blood  must  belong  to  either  group 
II  or  III  in  order  to  be  of  any  value  in  grouping  other  bloods.  The 
group  to  which  a  blood  belongs  becomes  fixed  by  the  third  year  of  life, 
and  remains  constant.  It  is  not  influenced  by  age,  disease  or  trans- 
fusion of  blood  belonging  to  another  group. 

It  will  be  seen  from  the  above  table  that  the  serimis  and  corpuscles 
of  the  same  groups  do  not  in  any  way  interact.  It  will  also  be  noted 
that  there  is  a  wide,  undetermining  variety  of  reactions  possible  in  the 
cases  of  group  I  and  IV.  The  reactions  in  the  two  remaining  groups  are 
more  limited  and  definite,  and  for  that  reason,  groups  II  or  III  only  may 
be  used  as  the  standards  in  the  ^NIoss  test. 

The  basis  of  the  blood  examination  for  transfusion  is  the  aggluti- 
nation reaction.  Agglutination  is  considered  as  an  early  stage  of 
hemolysis  and  is  always  present,  hemolysis  never  occurring  without  a 
primary  agglutination  of  the  blood  cells,  while,  on  the  other  hand, 
agglutination  may  occur,  and  does  occur  without  hemolysis.  It  is 
from  this  agglutination  that  we  arrive  at  our  conclusions.  The  serum 
of  a  given  blood  contains  a  protective  agent  (antihemolysin)  for  its  ovra 


AGGLUTINATION  TEST  197 

corpuscles,  this  serum  having  a  tendency  to  prevent  hemolysis.  The 
serum  does  not  contain  a  corresponding  antiagglutinin,  so  hemolysis 
may  be  prevented  without  in  any  way  hindering  the  agglutination 
reaction.  In  the  original  method  of  Moss,  two  platinum  loopfuls  of 
the  agglutinating  serum  were  added  to  one  loopful  of  corpuscles  from 
the  blood  to  be  tested.  By  this  method  oftentimes  the  stage  of  aggluti- 
nation was  so  transient  that  its  presence  was  not  recognized,  and  the 
agglutination  went  on  to  complete  hemolysis.  The  correct  interpre- 
tation of  the  test  was  therefore  impossible,  as  the  observer  failed  to 
recognize  the  determining  factor:  agglutination.  To  remedy  this, 
Brem,  besides  the  two  loopfuls  of  agglutinating  serum  and  one  loopful 
of  the  corpuscles  of  the  blood  to  be  tested,  added  one  loopful  of  the 
protecting  serum,  that  is,  serum  of  the  same  blood  from  whence  the 
corpuscles  were  derived.  This  protective  serum,  as  we  stated  above, 
contains  antihemolysins  but  no  agglutinins.  In  this  way  the  aggluti- 
nation is  not  in  any  way  affected,  but  the  hemolysis  of  the  blood  cells 
is  retarded  or  prevented,  so  giving  a  relatively  slow,  definite,  easily 
recognizable  stage  of  agglutination.  The  technic,  based  upon  these 
considerations,  is  as  follows: 

Ten  to  twenty  drops  of  blood  are  collected  in  a  small  test-tube  from 
the  lobe  of  the  ear.  This  is  allowed  to  clot  and  then  the  tube  is  centri- 
f  uged  so  as  to  obtain  a  clear  serum  above.  This  is  the  protective  serum 
when  used  with  its  own  corpuscles,  but  when  it  is  used  with  the  cor- 
puscles of  another  blood  it  is  called  the  agglutinating  serum.  In  another 
small  test-tube  are  collected  2  drops  of  blood  in  about  1  c.c.  of  solution 
composed  of  1.5  gm.  sodium  citrate,  0.9  gm.  sodium  chloride  in  100  c.c. 
of  distilled  water.  This  gives  approximately  a  5  per  cent,  suspension  of 
the  corpuscles.    This  tube  requires  no  further  preparation. 

Upon  cell  slides  rimmed  with  petrolatum  to  prevent  evaporation  are 
made  ordinary  hanging  drops. 

On  one  slide  is  placed: 

Two  loopfuls  of  standard  serum  (agglutinating  serum),  plus 

One  loopful  of  the  suspension  of  corpuscles  of  the  blood  to  be  tested, 
plus 

One  loopful  of  the  protecting  serum;  that  is,  the  serum  from  the 
same  blood  as  the  corpuscles. 

On  the  other  slide: 

Two  loopfuls  of  the  unknown  serum  (of  the  blood  to  be  tested),  plus 

One  loopful  of  the  suspension  of  corpuscles  from  the  standard  or 
known  blood,  plus 

One  loopful  of  its  protective  serum. 

It  will  be  seen  from  the  above  table  that  one  slide  contains  the 
standard  or  known  serum,  while  the  other  the  standard  or  known 
corpuscles.  Deductions  are  made,  using  the  standard  serum  and  cor- 
puscles as  a  basis  (group  II  or  III  used  as  the  standard  groups)  after 
the  agglutination  is  recognized. 

For  instance,  if  using  group  II  as  a  standard  we  get  agglutination  in 
the  slide  containing  the  standard  serum  and  none  in  the  slide  containing 


198  BLOOD  TRANSFUSION 

the  standard  corpuscles  the  undetermined  blood  is  of  group  I.  From 
the  above  table  we  will  find  that  the  serum  of  the  standard  blood  (group 

II  in  this  case)  agglutinates  the  corpuscles  of  groups  I  and  III  and  not 
of  groups  II  or  IV,  and  that  the  corpuscles  of  this  standard  group  II 
are  agglutinated  by  the  sermns  of  groups  III  and  IV  and  not  by  groups 
I  or  II.  Then,  since  there  is  agglutination  in  the  slide  containing  the 
seriun  of  the  standard  group  II  the  undetermined  or  unknown  blood 
must  be  either  of  group  I  or  III.  In  the  other  slide  containing  the  cor- 
puscles of  the  standard  group  II  there  is  no  agglutination,  so  the 
undetermined  or  unknown  blood  must  be  either  of  group  I  or  III. 
Since  group  I  satisfies  the  agglutinating  reaction  in  both  instances  the 
unknown  blood  must  belong  to  that  group. 

If  agglutination  occurred  in  both  slides  prepared  as  stated  above,  by 
similar  deductions  we  find  the  undetermined  blood  would  belong  to 
group  III,  as  the  standard  serum  agglutinates  the  corpuscles  of  groups 
I  and  III  and  not  of  groups  II  or  IV,  while  the  standard  corpuscles  are 
agglutinated  by  the  serimis  of  groups  III  and  IV  and  not  by  groups  I 
or  II.  As  the  serum  and  corpuscles  of  group  III  satisfy  the  agglutinating 
reaction  in  both  instances  the  blood  being  tested  belongs  to  that  group. 

Taking  the  third  possible  reaction,  if  no  agglutination  occm^red  in 
the  slide  containing  the  sermn  of  the  standard  blood,  and  agglutination 
was  present  in  the  slide  containing  the  standard  corpuscles,  the  undeter- 
mined blood  would  be  of  group  IV,  since,  from  the  table  given  above, 
we  see  that  the  standard  blood  (group  II)  agglutinates  the  corpuscles 
of  groups  I  and  III,  and  not  of  II  or  IV.  The  standard  corpuscles  of 
group  II  (the  standard  blood  used  in  this  instance),  are  agglutinated 
by  the  serums  of  groups  III  and  IV,  and  not  by  I  or  II.  Therefore  the 
serum  and  corpuscles  of  group  IV  satisfy  the  agglutinating  reaction  of 
group  II,  the  standard;  consequently,  the  blood  tested  belongs  to 
group  IV. 

Lastly,  if  there  occurs  no  agglutination  in  either  slide,  the  unknown 
blood  is  of  the  same  group  as  the  standard  blood  used,  as  bloods  of  the 
same  group  do  not  in  any  way  interact. 

These  are  the  four  possibilities  in  using  group  II  as  a  standard.  The 
method  of  deduction  is  identical  to  that  given  above  when  using  group 

III  as  the  standard. 

An  endeavor  should  always  be  made  to  have  the  donor  and  the 
recipient  of  the  same  group,  so  reducing  to  a  minimum  the  possibilities 
of  reactions.  If,  in  an  emergency,  blood  must  be  given  immediately, 
or  if  the  recipient  be  a  member  of  group  I  or  III,  the  rarer  groups, 
certain  deviations,  may  be  practised  in  which  bloods  of  unlike  groups 
can  be  used.  Under  such  conditions,  the  senmi  of  the  recipient  must 
never  agglutinate  the  corpuscles  of  the  donor,  while  the  serum  of  the 
latter  may  agglutinate  the  corpuscles  of  the  patient.  The  serum  of  the 
donor,  as  it  enters  the  blood  stream  of  the  recipient,  is  diluted  to  such  an 
extent  as  to  be  practically  inactive.  The  lack  of  agglutination  of  the 
patient's  corpuscles  is  in  part  prevented  by  the  fact  that  the  recipient's 
corpuscles  are  protected  by  his  own  serum:  i.  e.,  the  protective  serum. 


AGGLUTINATION   TEST  199 

Vincent's  Method  of  Determining  the  Moss  Grouping  of  Blood. — 
Because  of  the  technical  difficulties  of  grouping  bloods  in  a  private 
home  without  any  laboratory  facilities,  Vincent  worked  out  a  method 
by  which  a  patient's  blood  group  can  be  determined  in  from  three  to 
five  minutes,  requiring  no  laboratory  facilities. 

In  making  the  test  one  must  have  on  hand  a  stock  serum  from  an 
individual  whose  blood  belongs  to  group  II  and  from  one  in  group  III. 
These  stock  serimis  are  obtained  by  drawing  blood  from  an  individual 
in  group  II  and  from  one  in  group  III.  The  serum  is  separated  from 
the  blood  by  centrifuging  or  allowing  the  blood  to  clot,  the  serum  from 
which  is  placed  in  a  sterile  bottle.  The  serum  is  preserved  by  adding  to 
it  enough  sodium  citrate  to  make  a  1.5  per  cent,  solution  and  chloro- 
form is  added  to  the  extent  of  .3  per  cent.  These  serums,  when  sterile, 
can  be  kept  indefinitely. 

Technic  of  Grouping  the  Blood. — One  drop  of  group  II  serimi  is  placed 
on  a  glass  slide  near  one  end,  and  one  drop  of  group  III  seriun  on  the 
same  slide,  near  the  other  end.  A  drop  of  blood  from  the  person  to  be 
grouped  is  mixed  with  each  of  the  serums  on  the  slide  and  the  reaction 
noted.  Clumping  of  the  corpuscles,  if  it  takes  place,  will  occur  in  from 
one  to  three  minutes,  and  can  be  readily  seen  with  the  naked  eye, 
appearing  as  a  brick  red  deposit.  The  various  groups  will  be  noted 
by  the  follomng  reactions: 

1.  If  agglutination  of  the  corpuscles  takes  place  in  the  group  II 
serum  and  not  in  the  group  III  serum,  the  blood  being  grouped  belongs 
to  group  III. 

2.  If  agglutination  is  noted  in  the  group  III  serum  and  not  in  the 
group  II  serum,  the  blood  being  grouped  belongs  to  group  II. 

3.  If  agglutination  is  noted  in  both  group  II  and  group  III  serums, 
the  blood  being  grouped  belongs  to  group  I. 

4.  If  agglutination  does  not  occur  in  either  serum,  the  blood  being 
grouped  belongs  to  group  IV. 

When  noting  the  reaction,  if,  by  simply  looking  at  the  slide  with  the 
naked  eye  there  be  any  doubt  as  to  whether  or  not  agglutination  has 
taken  place,  this  can  be  definitely  determined  by  placing  the  slide 
under  the  microscope.  From  the  above  it  may  be  noted  that  if  one  has 
on  hand  a  stock  serum  belonging  to  group  II  and  to  group  III,  the 
technic  of  grouping  blood  is  very  simple  and  can  be  done  in  a  few 
minutes,  even  without  laboratory  facilities.  The  simplicity  and  rapid- 
ity with  which  it  can  be  done  is  the  only  advantage  it  has  over  Brem's 
technic  as  previously  described. 

The  determination  of  the  hemolytic  reactions  of  blood  by  the  ]Moss 
method  in  the  selection  of  donors,  has  proved  very  satisfactory  in  our 
hands.  Since  adopting  this  method,  three  hundred  and  fifty  transfusions 
have  been  made  without  encountering  a  single  case  of  hemolysis.  The 
milder  reactions  have  been  rare.  These  have  been  manifested  by  a 
chill  in  5  per  cent,  of  the  cases  and  by  a  rise  in  temperatiu-e  occurring 
on  the  same  or  following  day  in  10  per  cent,  of  the  cases. 

Except  in  extreme  emergency,  one  is  never  justified  in  making  a 


200  BLOOD  TRANSFUSION 

blood  transfusion  without  first  having  made  a  hemolytic  test  between 
the  two  bloods  to  be  mixed.  Even  between  near  relatives,  such  as 
sister  to  sister  or  parent  to  child,  etc.,  severe  fatal  hemolysis  may  occur 
from  mixing  the  two  bloods.  In  case  of  a  large  family  in  which  the 
father  and  mother  are  not  in  the  same  blood  group,  usually  some  of  the 
children  will  be  in  the  same  group  as  the  mother  and  some  in  the 
father's  group,  and  occasionally,  some  in  still  another  group.  Thus  it 
is  plain  that  a  brother  might  be  a  suitable  donor  for  one  brother  but 
not  for  another;  also,  he  might  be  a  suitable  donor  for  one  parent  and 
not  for  the  other,  thus  making  it  a  dangerous  procedure  to  transfuse 
one  member  of  a  family  from  another  member  without  first  determining 
the  hemolytic  action  of  one  blood  with  the  other. 

Methods  of  Transfusion. — 1.  Direct  method  by  means  of: 

(o)  Sutiu-e  of  vessel  to  vessel  as  practised  by  Carrel,  jNIurphy  and 
others. 

1^  (b)  By  use  of  a  paraffin-coated  cannula  interpolated  in  the  blood 
stream  as  devised  by  Brewer^  and  the  two-piece  tube  of  Bernheim.- 

(c)  By  use  of  one  cannula,  bringing  intima  to  intima  as  represented 
by  the  Crile  method. 

2.  The  indirect  methods: 

(a)  Needle  and  syringe  method  of  Lindeman^  and  Crotti.^ 

(b)  The  direct  and  indirect  valve  and  syringe  method  of  INIiller,^ 
Unger®  and  others. 

(c)  The  indirect  paraffin  tube  methods  of  Kimpton  and  Brown, ^ 
David  and  Curtis^  and  Percy .^ 

(f/)  By  drawing  blood  into  a  receptacle  containing  anticoagulants, 
such  as  the  citrate  methods  of  ^YeiP°  and  liCwisohn,^'  and  the  use  of 
Herudin  by  Satterlee  and  Hooker. 

(e)  The  method  of  drawing  blood  into  a  receptacle,  defribinating, 
then  injecting  the  defibrinated  blood  into  the  vein  through  a 
needle. 

The  direct  method  of  transfusion  by  bringing  intima  to  intima  would 
be  the  ideal  method  were  it  not  for  the  fact  that  it  requires  expert 
surgeons  to  perform  the  operation  and  that  there  is  no  way  of  deter- 
mining with  any  degree  of  accm-acy  the  quantity  of  blood  transfused. 
On  account  of  the  technical  difficulties  of  the  operation  the  direct 
methods  of  transfusion  have  been  almost  entirely  replaced  by  the 
various  indirect  methods. 

Percy's  Method  of  Transfusion. — The  method  is  an  indirect,  closed 
method  and  consists  of  drawing  blood  into  a  specially  designed  glass 
tube  and  then  injecting  it  into  the  vein  of  the  recipient.  The  tube  is 
coated  inside  with  solid  grocers'  paraffin  and  liquid  paraffin  is  floated 

1  Jour.  Am.  Med.  Assn.,  Januarj-  30,  1909.  2  n^jj^  October  9,  1915. 

.  3  Am.  Jour.  Dis.  of  Child.,  1913,  vi,  28. 
*  Surg.,  GjTiec.  and  Obstet.,  1914,  xviii,  236. 

6  Medical  Record,  September  11,  1915.  « Ibid. 

7  Jour.  Am.  Med.  Assn.,  July  12,  1913.  » Ibid.,  Ixii,  775. 
'  Svirg.,  Gynec.  and  Obst.,  September,  1915. 

10  Jour.  Am.  Med.  Assn.,  January  20,  1915.  "  Am.  Jour.  Med.  Sc,  1915,  cl,  886. 


TECH  NIC  OF  TRANSFUSING  THE  BLOOD  201 

on  top  of  the  blood,  preventing  the  blood  from  coming  in  contact  with 
the  air. 

Description  of  Tube.— The  tube  to  be  described  is  a  modification  of 
the  Brown  tube,  which  was  changed  with  the  object  of  making  a 
venous  transfusion  tube  and  also  a  tube  more  easily  constructed.  It 
consists  of  a  glass  cylinder,  5  cm.  in  diameter,  with  a  cannula  leading 
from  one  end,  the  other  end  being  drawn  out  into  a  tube  about  1  cm. 
in  diameter,  to  which  a  Y-connection  containing  a  two-way  valve  is 
made.  To  one  arm  of  the  Y  a  rubber  tube  is  attached  for  suction  to  aid 
in  filling  the  tube  and  to  the  other  arm  a  rubber  bulb  is  connected  to  aid 
in  injecting  the  blood.  The  tube  differs  from  the  Brown  tube  in  that 
there  is  no  side  tube  coming  off  from  the  cylinder,  and  the  upper  end 
of  the  cylinder,  instead  of  being  closed  with  a  large  cork,  is  dra\\m  out 
into  a  tube  for  the  Y  connections,  as  described  above.  The  cannula 
part  of  the  tube  is  so  constructed  that  it  can  be  inserted  directly  into 
the  vein  of  the  donor  and  then  into  the  recipient.  x\n  open  dissection 
of  the  vein  of  both  donor  and  recipient  is  made  for  two  reasons:  (1) 
If  the  operation  were  done  subcutaneously,  it  would  be  necessary  to 
use  a  needle  with  a  rubber  connection  to  the  cannula,  which  connection 
would  make  a  roughened  area  which  would  favor  clotting,  whereas 
with  the  smooth,  paraffin-coated  cannula  there  is  no  such  tendency. 
(2)  After  the  tube  is  filled  with  blood,  the  cannula  can  be  inserted  into 
a  vein  of  the  recipient  without  delay,  an  essential  featm^e  because  of  the 
tendency  to  clot  after  blood  has  been  withdrawn. 

Preparation  of  Tube. — The  tube  should  be  cleansed  by  washing  with 
water,  alcohol  and  then  with  ether,  and,  after  it  is  perfectly  dry,  2 
ounces  of  melted  grocers'  paraffin  are  poured  into  the  tube  through  the 
upper  end.  It  is  then  wrapped  in  a  towel  and  placed  in  a  steam  auto- 
clave for  fifteen  minutes  under  fifteen  pounds'  pressiu"e,  after  which, 
with  sterile  rubber  gloves  over  the  hands,  the  tube  is  rolled  around  while 
cooling  so  that  every  part  of  the  inside  is  covered  with  melted  paraffin 
and  any  excess  allowed  to  run  out  of  the  large  end.  Care  should  be 
taken  not  to  allow"  the  cannula  to  become  plugged  with  paraffin.  If 
it  does  the  tip  is  warmed  over  a  fiame  and  the  paraffin  allowed  to  run 
back  into  the  tube.  Sterilizing  the  rubber  tubing,  Y-valve  and  mouth- 
piece is  done  by  placing  them  in  a  towel  and  autoclaving  in  the  same 
WSLV  and  at  the  same  time  as  the  transfusion  tube  or  boiling  them  for 
twenty  minutes.  The  atomizer  bulb  is  thoroughly  washed  with 
alcohol  to  sterilize  it.  When  ready  to  use  the  connections  are  all  made 
and  2  ounces  of  sterile  liquid  paraffin  aspirated  into  the  tube  through 
the  cannula  by  means  of  suction  at  the  mouth-piece.  A  simpler  method 
of  sterilizing  the  tube  consists  of  first  pom-ing  the  melted  paraffin  into 
the  tube,  then  carefully  heating  the  tube  over  a  gas-burner  until  the 
paraffin  in  the  tube  begins  to  smoke.  The  excess  paraffin  is  allowed  to 
run  out  of  the  tube  and  the  tube  is  carefully  rolled  with  the  hands 
while  the  paraffin  is  cooling,  thus  evenly  coating  the  entire  tube. 

Technic  of  Transfusing  the  Blood. — ^The  arms  of  both  the  donor  and 
the  recipient  are  prepared  as  for  a  surgical  operation.    Proper  constric- 


202 


BLOOD  TRANSFUSION 


Fig.  2. — 1,  2,  preparation  of  the  arms  of  donor  and  recipient  for  blood  transfusion; 
la,  2a,  dissection  of  the  veins  of  donor  and  recipient  shown  in  detail.  (Surgical 
Clinics  of  Chicago.) 


TECHNIC  OF  TRANSFUSING  THE  BLOOD 


203 


Fig.  3 — S,  method  of  obtaining  blood  from  donor.  Note  layer  of  liquid  paraffin 
floating  on  blood.  Insert  shows  detail  of  the  two-way  valve.  The  operator  and  his 
assistant  hold  the  vein  over  the  cannula  by  means  of  traction  on  the  mosquito  clamps. 
Gentle  suction  is  made  by  a  second  assistant.  4.  the  cannula  of  the  transfusion  tube 
inserted  in  the  vein  of  the  recipient.  The  edges  of  the  vein  are  held  in  the  same  way. 
Gentle  air  pressure  is  applied  above  the  blood  chamber  by  means  of  a  rubber  atomizer 
bulb.     (Surgical  Clinics  of  Chicago.) 


204  BLOOD  TRANSFUSION 

tion  of  the  donor's  arm  is  essential  if  one  wishes  to  draw  off  a  large 
quantity  of  venous  blood  rapidly.  Constriction  by  means  of  a  rubber 
tube  is  not  satisfactory  because  the  amount  of  pressure  is  not  known, 
nor  can  the  pressure  be  varied  as  desired.  An  ordinary  blood-pressure 
apparatus  placed  about  the  arm  and  pumped  up  to  50  to  SO  mm.  of 
mercury,  depending  upon  the  rapidity  with  which  the  blood  flows, 
makes  an  excellent  constrictor.  By  this  means  the  venous  circulation 
is  impeded  but  not  the  arterial,  thus  making  the  entire  arm  a  blood 
reservoir,  and  so  increasing  the  pressure  in  the  vein  elected. 

It  is  imperative  to  use  a  separate  set  of  instruments  on  different  tables 
for  donor  and  patient  in  order  not  to  transmit  infections  from  patient 
to  donor.  Under  local  anesthesia,  using  0.5  per  cent,  novocain  solution 
intradermally,  an  incision  is  made  over  the  cephalic  vein  just  above  the 
elbow  on  both  the  donor  and  the  recipient,  and  a  ligature  placed  about  the 
vein  on  its  proximal  portion  in  the  donor  and  on  its  distal  portion  in  the 
recipient.  Small  Carrel  clamps  are  placed  on  that  portion  of  the  vein 
away  from  the  ligature  in  each  patient  and  a  longitudinal  incision 
3  mm.  long  made  through  all  coats  of  each  vein  midway  between 
clamp  and  ligature.  Small  mosquito  retention  clamps  are  placed 
on  the  two  edges  of  the  incision  in  each  vein  in  order  to  hold  them 
open. 

Just  before  the  tube  is  inserted  into  the  donor's  vein  about  25  c.c. 
of  sterile  liquid  paraffin  are  aspirated  into  the  tube.  The  cannula  is 
placed,  pointing  distally,  into  the  vein  of  the  donor,  and  the  Carrel 
clamp  released  from  the  vein.  Slight  suction  will  facilitate  filling  of 
the  tube  with  blood.  The  blood  is  well  protected  from  the  sides  of  the 
glass  by  the  paraffin  coat.  As  the  tube  fills  the  liquid  paraffin  floats 
over  the  blood,  thus  preventing  the  blood  from  coming  in  contact  with 
air.  As  soon  as  the  tube  is  filled,  which  in  our  experience  averages  about 
three  and  one-half  minutes  to  withdraw  600  c.c.  of  blood,  the  Y-valve 
is  closed,  the  cannula  removed  from  the  vein  and  the  small  clamp 
reapplied  to  the  donor's  vein. 

The  cannula  is  now  quickly  transferred  to  the  limien  of  the  vein  of  the 
recipient  and  the  Carrel  clamp  released.  The  blood  will  now  flow  into 
the  vein  of  the  recipient  toward  the  heart,  the  velocity  of  which  flow 
may  be  controlled  by  careful  pumping  of  the  rubber  atomizer  bulb. 
As  soon  as  it  is  evident  that  the  blood  is  flowing  properly  an  assistant 
may  release  the  constrictor  from  the  donor  and  ligate  the  vein  distally 
to  the  opening  from  which  the  blood  has  been  taken.  Not  more  than 
five  minutes  should  be  utilized  in  obtaining  the  blood.  The  tube  can 
be  emptied  in  about  a  minute  and  a  half,  but  greater  deliberation  is 
advisable,  so  that  possible  hemolytic  phenomena  may  be  noticed,  acute 
dilatation  of  the  heart  avoided  and  that  aeration  of  this  venous  blood 
may  be  more  ready.  Inhalation  of  oxygen  in  very  weak  patients  is 
advisable  during  the  injection  of  large  amounts  of  venous  blood.  The 
length  of  time  reciuired  to  fill  the  tube  with  blood  varies  with  different 
donors.  It  is  well  to  have  two  tubes  ready,  so  that  if  it  is  found  that 
the  first  tube  fills  slowly,  taking  more  than  five  minutes  to  get  the 


REACTIONS  FOLLOWING  TRANSFUSION  205 

required  amount,  the  process  may  be  repeated  with  the  second  tube, 
aspirating  only  the  remainder  of  the  required  amount  of  blood. 

Factors  of  Safety. — The  chief  points  to  be  borne  in  mind  in  blood 
transfusion  are  the  avoidance  of  hemolysis,  air  ambolism,  clot  embolism 
and  acute  dilatation  of  the  heart. 

The  greatest  risk  from  the  operation  is  that  from  hemolysis.  This 
danger  can  be  avoided  in  the  vast  majority  of  cases  if  careful  hemolytic 
and  agglutination  tests  are  always  made  preliminary  to  transfusion. 
While  laboratory  methods  have  their  limitations  and  are  not  infallible, 
still,  if  the  tests  are  always  carefully  made,  the  danger  from  hemolysis 
is  slight. 

The  danger  from  air  embolus  and  clot  embolus  can  always  be  avoided 
if  proper  care  is  exercised  in  carrying  out  the  technic  of  the  operation. 

The  danger  of  acute  dilatation  of  the  heart  is  probably  not  as  great 
as  is  generally  supposed.  So  far  the  author  has  not  encountered  a 
case  in  which  there  was  any  evidence  of  the  heart  having  been  embar- 
rassed by  the  transfusion.  It  is  well,  however,  not  to  inject  the  blood 
too  rapidly  in  very  weak  and  anemic  patients,  especially  if  it  be  the 
first  transfusion. 

Advantages  of  the  above  method  of  transfusion  are: 

1.  Ivno"UTi  quantities  of  blood  may  be  administered. 

2.  As  much  as  600  to  700  c.c.  of  blood  can  be  given  in  from  five  to 
eight  minutes. 

3.  Venous  blood  is  utilized,  so  that  arteries,  such  as  the  radial,  are 
not  destroyed. 

4.  Transfusion  can  be  made  without  danger  of  contaminating  the 
donor  with  the  blood  of  the  recipient. 

5.  The  blood  does  not  come  in  contact  with  the  air  during  the  entire 
operation. 

6.  There  is  direct  communication  between  the  vein  and  the  chamber 
by  a  simple  paraffin-lined  glass  cannula.  There  are  no  metal,  rubber 
or  other  connections  which  might  cause  resistance  to  the  flow  of  blood 
and  thus  favor  the  formation  of  a  clot. 

7.  Plain,  whole  blood  is  administered  in  its  normal  state.  The  blood 
is  not  diluted  with  any  foreign  substance  and  not  traumatized  by 
beating,  as  in  the  citrate  method;  nor  is  it  traumatized  by  passing 
through  a  series  of  valves  and  connections,  as  it  might  be  in  some  of  the 
other  indirect  methods  of  transfusion. 

Reactions  following  Transfusion. — The  majority  of  our  patients  have 
experienced  no  noticeable  reaction  whatsoever.  In  about  5  per  cent, 
of  cases  a  slight  chill  has  occurred,  followed  by  temperature,  and  in  an 
additional  5  per  cent,  a  mild  temperature  developed  the  same  evening 
or  day  following  the  transfusion.  This  applies  to  transfusions  in  which 
the  patient  and  donor  were  in  the  same  blood  group,  as  classified  by 
Moss.  Whenever  we  deviated  from  this  and  used  a  donor  from  a 
different  blood  group  than  that  of  the  recipient,  as  was  occasionally 
necessary,  the  transfusion  was  usually  followed  by  a  marked  chill  and 
temperature.    A  donor  from  a  different  group  than  that  of  the  recipient 


206  BLOOD   TRANSFUSION 

was  never  used  except  when  the  patient  was  in  one  of  the  rarer  groups 
and  it  was  difficult  to  find  a  donor  belonging  to  the  same  group.  In 
these  instances  a  donor  was  chosen  from  group  IV,  a  group  whose 
corpuscles  would  not  be  agglutinated  by  the  serum  of  the  recipient. 

A  number  of  operators  using  the  citrate  method  have  noted  a  com- 
paratively high  percentage  of  reaction  following  transfusion.  This  is 
probably  due  to  two  causes:  (1)  the  introduction  of  the  sodium 
citrate  into  the  circulation,  which  may  be  slightly  toxic  to  some 
individuals;  (2)  the  whipping  of  the  blood  and  exposure  to  the  air  in 
mixing  it  with  the  citrate  solution  may  cause  some  change  in  the  blood 
which,  when  injected  into  the  circulation,  may  help  to  account  for  the 
chills  and  temperatiu-e. 

The  clinical  effect  of  transfusions  apparently  is  not  impaired  by  these 
slight  reactions,  which  not  infrequently  do  occur.  Novy's^  experiments 
in  the  toxicity  of  normal  blood  serum  are  interesting.  He  believes  that 
normal  serum  is  always  toxic  and  that  the  effects  produced  by  the 
injection  of  serum  vary  with  the  method  of  preparing  the  serimi.  A 
serimi  made  by  defibrinating  with  glass  beads  was  found  to  be  more 
toxic  than  one  prepared  by  simply  whipping  with  a  glass  rod.  He  also 
found  that  with  whole  blood  some  change  takes  place  in  the  blood  by 
being  out  of  the  body  a  few  minutes,  rendering  the  blood  toxic.  This 
is  illustrated  by  the  following  experhnent:  When  10  c.c.  of  blood 
were  drawn  from  a  rabbit  and  injected  intravenously  into  a  guinea-pig 
with  the  least  possible  delay  it  caused  very  little  or  no  reaction.  On 
the  other  hand,  when  such  blood  was  kept  in  the  sjTinge  for  three 
minutes  before  it  was  injected  the  blood  became  toxic,  2  c.c.  of  which 
was  sufficient  to  kill  the  animal. 

The  symptoms  of  hemolysis  or  "anaphylactoid"  phenomena,  as 
spoken  of  by  Brem,  which  follow  transfusion  when  one  blood  is  incom- 
patible with  the  other  are  quite  t^-pical,  and,  as  a  rule,  occur  within  a 
few  seconds  from  the  time  the  transfused  blood  first  enters  the  circu- 
lation. Before  using  the  Moss  group  method  of  selecting  donors  the 
author  met  with  three  of  these  severe  reactions,  two  of  which  resulted 
fatally,  one  living  twenty  days  and  the  other  twenty-one  days  after 
transfusion.  The  s}Tnptoms  were  practically  the  same  in  all  3  cases; 
the  2  which  resulted  fatally  ran  practically  the  same  coiuse. 

The  following  report  illustrates  the  symptoms  and  course  of  a  case 
of  hemolysis  from  transfusion.  The  case  transfused  was  a  tuberculous 
patient,  suffering  from  Pott's  disease  with  psoas  abscess,  also  tuber- 
culosis of  the  ribs.  On  making  a  hemolytic  test  a  marked  hemolytic 
reaction  existed  between  her  blood  and  her  husband's,  but  a  test  with 
the  sister's  blood  was  negative,  so  she  was  chosen  as  the  donor.  Five 
hvmdred  cubic  centimeters  of  blood  were  taken  from  the  donor  and 
after  about  250  c.c.  had  been  given  to  the*  recipient,  she  suddenly  com- 
plained of  a  peculiar  feeling  over  her  entire  body  and  of  severe  pain  low 
down  in  the  spine  radiating  along  both  sciatic  nerves.    The  transfusion 

'  Jour.  Am.  Med.  Assn.,  July  15,  1916,  p.  193. 


REACTIONS  FOLLOWING  TRANSFUSION  207 

was  stopped  immediately  without  giving  the  remaining  250  c.c.  of 
blood  in  the  tube.  Chills  and  vomiting  began  at  once.  A  peculiar 
biuret-pink  blush  flushed  the  woman's  face  and  body,  being  strikingly 
intense  on  the  palms.  Sweating,  so  profuse  that  droplets  formed  on  the 
fingers  and  the  palms,  was  noted  immediately.  Great  respiratory 
distress  accompanied  these  signs,  persisting  somewhat  longer  than  the 
characteristic  blush  which  quickly  changed  to  a  transient  cyanosis,  as 
though  the  capillaries  had  been  suddenly  gorged  to  their  full  capacity 
and  then  had  suddenly  contracted  to  their  utmost.  This  entire  chain 
of  symptoms  occurred  within  three  minutes  of  the  beginning  of  trans- 
fusion. The  vomiting  and  chills  persisted  in  their  full  intensity  for 
about  one  hour,  when  the  temperature  mounted  to  101°,  returning 
to  normal  within  twenty-four  hours.  The  vomiting  continued,  regard- 
less of  food  (bile  and  mucus),  at  intervals  of  from  a  half  to  a  few  hours. 
Two  hours  after  the  transfusion  bleeding  began  from  the  uterus  and  the 
small  cutaneous  wound  in  the  arm,  and  it  was  uncontrollable  except  by 
tight  compression  of  the  entire  arm  and  heavy  sealing  of  the  wound 
with  collodion.    Bleeding  subsided  within  twelve  hours. 

Six  hours  after  transfusion  a  peculiar  yellow  color,  different  from  yet 
suggesting  jaundice,  made  its  appearance  over  the  entire  body,  includ- 
ing the  sclerse.  This  color  disappeared  in  thirty-six  hours.  Within  two 
hours  after  transfusion  blood  appeared  in  the  urine.  This  was  followed 
by  a  complete  suppression  of  urine,  persisting  for  thirty-six  hours, 
when  2  ounces  were  passed  in  the  next  twenty-four  hours.  The  quan- 
tity of  urine  increased  about  2  ounces  daily  to  10  or  12  ounces. 

One  week  after  transfusion  an  urticaria  appeared  over  the  entire 
body,  persisting  for  about  a  week,  and  being  followed  by  a  peeling 
resembling  the  scaling  of  a  scarlet-fever  rash.  Constant  nausea  and 
vomiting  persisted  without  abatement.  The  patient  gradually  lost 
strength  and  died  at  the  end  of  three  weeks  without  evidence  of  any 
terminal  infection. 

It  may  be  noted  that  the  donor  in  this  case  was  the  patient's  sister. 

StnvniARY.- — 1.  Transfusion  of  blood  is  the  most  efficient  means  at 
our  command  for  treating  hemorrhage  and  the  majority  of  hemorrhagic 
diseases,  as  well  as  many  of  the  wasting  diseases. 

2.  The  proper  selection  of  donors  by  adequate  preliminary  tests  for 
compatibility  is  essential. 

3.  Amounts  of  from  500  to  800  c.c.  of  whole  blood,  repeated  at 
intervals  of  seven  to  fifteen  days,  are  most  desirable. 

4.  A  simple,  rapid  method  of  transfusing  should  be  used.  This 
should  preferably  be  one  in  which  plain,  whole  blood  is  administered, 
without  mixing  with  any  foreign  substance;  furthermore,  the  blood 
should  not  be  unduly  exposed  to  the  air,  and  the  interval  that  it  is  out 
of  the  circulation  should  be  reduced  to  a  minimum.  An  indirect, 
closed  method  by  means  of  a  prepared  container  seems  to  best  answer 
these'requirements. 


EFFICIENCY  OF  EADmi  IX  3IALICIXAXT 

DISEASE. 

By  ROBERT  ABBE,  M.D. 

Ix  considering  the  subject  of  this  title,  we  must  ask  ourselves  two 
questions : 

1.  T\^at  can  we  regard  as  definite  knowledge  of  the  action  of  radium 
as  a  physical  force? 

2.  "VSTiat  effect  is  seen  by  its  use,  on  vital  growth  in  health  and 
disease? 

Without  an  intelligent  appreciation  of  this  first  step  we  are  not 
prepared  to  ask  the  question — 

"WTiat  is  its  effect  on  malignant  disease?" 

Under  the  latter  head  we  must  also  ask  ourselves:  "\Miat  constitute 
the  essential  characteristics  of  malignant  tumors?" 

No  observer  of  the  action  of  radium  can  fail  to  be  impressed  with  its 
terrific  penetrating  force,  which  no  material  substances,  even  metals, 
are  capable  of  resisting.  The  severe  test,  with  an  inch  thickness  of 
lead,  shows  that  this  is  a  barrier  to  its  penetration  only  for  a  time. 
One  thinks  he  is  immune  from  its  action  when  he  carries  radium  in  a 
lead  box  of  a  quarter  inch  thickness,  but  soon  discovers  his  fingers 
becoming  tender  from  it. 

The  many  streams  of  penetrating  particles  emanate  in  unceasing 
flow  from  the  eternal  disintegration  of  this  material.  They  travel  in 
undeviating  lines  in  all  directions,  and  barriers  of  A'ar\dng  resistance 
retard  them  only  for  a  time.    They  enter  space,  but  are  never  lost  in  it. 

The  nature  of  this  matter  is  now  sufficiently  understood  to  define 
it  as  a  discharge  of  infinitely  small  particles  mostly  bearing  an  electric 
current,  some  positive  and  some  negative,  called  "electrons."  The 
eternal  breaking  up  of  radium  particles  is  not  unlike  the  change  and 
decay  that  characterize  all  matter,  and  differs  only  in  being  so  much 
faster  than  anything  heretofore  knoT\TL,  that  it  can  be  seen,  measured, 
and  applied.  All  other  metals  are  undergoing  this  forcible  change, 
but  with  them  it  is  so  many  million  times  slower,  that  it  cannot  be 
identified,  studied  or  used,  though  it  can  be  computed. 

The  force  we  are  dealing  with,  then,  is  a  stream  of  electrons  which 
we  spray  upon  a  diseased  part  and  study  the  effect  which  follows. 
Wliether  we  use  a  nearly  pure  salt  of  radium,  like  the  pure  radium  bro- 
mide, or  an  impure  radium-barium  sulphate,  chloride  or  carbonate, 
of  one-third  or  one-tenth  strength,  we  are  applying  the  same  force  and 
obtain  the  same  effect  if  we  give  a  proportionate  exposure. 

VOL.  1—14  (  209  ) 


210 


EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 


It  will  be  essential  to  intelligent  understanding  of  the  action  and 
value  of  radium  to  know  a  little  of  the  detailed  physics  of  electrons.  A 
few  words  com])rehend  the  whole. 

There  are  three  kinds  of  particles  issuing  from  the  disintegrating 
atom : 

One  slow  mo\ing  and  heavier  than  the  others,  each  particle  carrying 
a  charge  of  positive  electricity  ("  if,  indeed,  it  be  not  electricity  itself, " 


Fig.  4.- 


-Schematic  representation  of  alpha,  beta  and  gamma  rays  from  a  surface  of 
radium  on  a  metal  block. 


as  Clifford  suggested).  This  alpha  series  travels  in  straight  lines,  but 
has  a  small  radius  of  action. 

The  second,  and  most  important,  the  beta  series,  much  faster  and 
lighter,  each  particle  carrying  negative  electricity. 

The  third,  the  gamma,  practically  a  neutral  electron,  travelling 
nearly  with  the  rapidity  of  light  and  almost  undeviated  by  the  mag- 
netic current. 


Fig.   5. — Alpha,  beta  and  gamma  rays  in  a  strong  magnetic  field. 

The  stream  of  rays  issuing  from  radium  moves  in  straight  lines  in  all 
directions  (Fig.  4).  When,  however,  it  is  placed  in  the  magnetic  field, 
between  two  poles  of  a  strong  battery,  only  the  gamma  rays  continue 
to  go  straight  while  the  beta  and  alphas  go  swirling  around  the  poles, 
one  in  one  direction  and  the  other  in  the  opposite,  obeying  the  law  of 
metallic  particles  in  the  magnetic  field  (Fig.  5).  Taking  advantage 
of  this  it  has  become  possible  to  study  the  effects  of  the  differentiated 
groups.    Two  simple  experiments  put  the  reader  in  the  way  of  under- 


EFFICIEXCY  OF  RADIUM  IX  MALIGXAXT  DISEASE 


211 


standing  the  full  value  of  each  group.    Their  effect  on  vital  growth  can 
be  demonstrated: 

First  experiment.  Let  radium  be  spread  on  a  small  block  of  lead, 
an  inch  square,  placed  at  right  angles  to  a  photographic  plate,  on  which 
are  standing  small  lead  pillars,  in  front  of  and  behind  the  block  (Fig. 
6).  In  a  few  moments  the  developed  photograph  shows  shadows 
of  all  columns  radiating  away  from  the  radium  (Fig.  7) .  At  the  foot 
of  each  column  is  an  mtensification  of  the  illumination  of  the  plate, 
due  to  a  series  of  secondary  rays  resulting  from  the  impact  of  all  these 
groups,  straight-travelling,  and  striking  the  little  lead  post,  set  up  on 
the  plate. 


Fig.   6 


Second  experiment.  Repeat  the  above  arrangement  of  lead  block, 
radium,  and  lead  posts  on  a  fresh  plate  and  place  this  in  the  field  of  a 
powerful  magnet.  On  developing  this  plate  an  entirely  different  picture 
is  shown  (Fig.  8).  The  posts  in  front  of  the  radiimi  again  show 
radiating  shadows,  but  another  set  now  appear  on  one  side  and  behind 
the  lead  block,  resulting  from  the  beta  rays,  torn  from  the  straight 
course  they  were  travelling  hand-in-hand  with  the  gammas,  and  made 
to  swirl  round  the  magnetic  pole,  in  obedience  with  laws  of  electrically 
charged  bodies,  and  casting  curved  shadows.  These  also  have  intensi- 
fied illumination  at  the  foot  of  each  post,  from  secondary  rays,  gener- 
ated always  where  any  obstruction  is  met.  This  experiment  can  now 
be  used  to  demonstrate  the  effort  of  isolated  beta  rays  (negative  elec- 
trons) on  living  cells.  (Fig.  9).  The  device  shown  provides  a  shelf 
on  which  are  showered  beta  and  gamma  rays  separated.  The  only 
scientist  competent  to  give  aid  in  perfect  demonstration  at  this  stage 


212 


EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 


FiQ.  7 


Fig.  8 


I  believed  to  be  Dr.  Alexis  Carrel,  who  had  been  growing  living  cells  of 
chicken  tissue  for  three  years  by  cultivation,  in  vitro,  in  a  warm  chamber 
under  strictest  guard  of  all  circumstances.     The  process  seemed  as 


EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 


213 


perfect  as  culture  of  bacteria  in  a  test-tube.  Every  other  day  an 
atomic  bit  of  new-grown  cells  had  been  cut  from  the  margin  of  two  days' 
growth,  and  placed  in  a  cell  or  a  microscopic  sHde,  sealed  hermetically 
in  modified  chicken  serum.  Thus,  generation  after  generation,  up  to 
nearly  three  hundred,  had  established  normal  growth  for  each  day, 
under  identical  conditions.  It  thus  became  possible  to  take  a  corre- 
sponding group  of  new  cells  day  after  day,  repeat  the  old  experiment 
and  add  the  new  ones,  of  an  identical  bit  of  tissue  subjected  to  isolated 
beta  rays  and  another  to  isolated  gamma  rays  for  a  half  hour,  and  culti- 
vated altogether  side  by  side[_for  two  days'  growth. 


Fig.  9 

This  experiment  Dr.  Carrel  eagerly  took  up  day  after  day,  appre- 
ciating its  significance,  and  pursuing  it  for  many  months  with  the 
following  striking  demonstrations : 

1.  The  beta  ray  uniformly  produced  great  retardation  of  the  cell 
growth.    The  gamma  gave  no  effect. 

2.  This  stunting  of  the  cells  was  persistent,  so  that  all  attempts  to 
make  them  grow  like  the  unradiimaized,  failed,  and  through  eight 
generations  the  dwarfed  cells  continued  as  dwarfs. 

(Further  work  was  prevented  by  Dr.  Carrel's  call  to  the  service  of  his 
country) . 

The  two  illustrations  of  normal  and  stunted  growth  here  shown  are 
from  studies  in  other  research  work  by  this  master,  but,  at  his  request, 
I  use  them  as  exact  illustrations  of  beta  ray  effects. 

Before  this  beautiful  demonstration  was  made  the  effects  of  radium 
on  animal  and  plant  life  had  been  confined  to  the  effects  of  mixed  rays. 
Although  from  the  first  Bequerel  had  showed  the  deviation  of  small 
pencils  of  the  rays  in  a  magnetic  field,  no  proof  of  the  separate  ray 
effects  had  been  known.  On  seeds  the  stunting  of  growth  by  mixed  rays 
of  radium  w^as  demonstrated  by  Danlos  to  whom  Madame  Curie  gave 


214  EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 

her  first  radium  for  study.    Thousands  of  experiments  on  every  kind 
of  bulb  flower  and  seed,  by  those  of  us  who  have  had  enough  to  make 


Fig.  10. — Two  days'  growth  of  living  cells  of  chicken  tissue  (300th  generation)  dwarfed 
by  thirty  minutes'  beta  ra>-s,  unaffected  In'  gamma  rays. 


Fiu.  11. — Growth  of  oats,  exposed  to  naked  radium  at  distances  from  i  to  4  inches. 
Twenty  rows.  Two  rows  for  comparison,  without  radium.  Exposure  six  days.  Growth 
after  planting,  one  month.  Nearest  two  rows  killed.  Fourth,  fifth,  sixth,  seventh,  stim- 
ulated.   Beyond  seventh  (Ij  inches)  all  retarded.     The  nineteenth  most  stunted  of  all. 


1- 

IJ  inch 

2  inch 

3  inch. 

No 
radium. 

Row 

1 

2     3 

4  j  5 

6 

77 

7     8 
79   63 

' 

10 

11 
62 

12    13 
58   50 

14 
59 

15 
63 

16 i  17    18 
60   64    62 

19    20 

'45    64 

N    N 

Weight,  grains 

0 

0     14 

70 

87 

61 

49 

74J95 

Ki 

lied. 

S 

tim 

ulat 

ed. 

St 

unt 

ed. 

EFFICIEXCY  OF  RADIUM  IX  MALIGXAXT  DISEASE  215 

tests,  all  show  the  same.  Let  us  illustrate  by  one  only  (Fig.  11).  If 
oats  be  exposed  to  mixed  radium  rays  for  varying  hours  and  planted 
simultaneously  the  longest  exposed  wUl  be  killed;  shorter  exposed  will 
germinate  and  die;  still  shorter  will  grow  stunted,  but  continue  to 
grow  or  flower,  dwarfed;  still  less  exposed  wWl  grow  less  than  normal; 
while  some  with  a  very  small  radiumizing  will  be  stimulated  and  grow 
above  the  normal. 

The  effect  on  animal  and  vegetable  life  is  the  same.  There  has  never 
been  any  known  difference  between  the  vital  force  actuating  a  cell  of 
animal  or  vegetable  structure.  It  is  fair  to  say  that  science  is  about 
ready  to  admit  that  electricity  is  the  basic  force  actuating  animal  life, 
energizing  nerves  and  muscles,  tactile  sense  and  cerebration.  The 
recent  study  of  cardiography  by  electrical  conduction,  whereby  dis- 
orders of  rhythm  and  function  of  the  heart  can  be  studied  a  half  mile 
from  the  bedside,  stand  sponsor,  if  any  were  needed,  for  placing  the 
responsibility  on  correct  electric  charges  for  normal  action  of  our  bodies 
and  on  disordered  electric  action  for  their  variations. 

Having  grasped  this  idea,  we  easily  take  the  next  step  and  note  the 
pathological  changes  in  the  cells  of  our  complicated  bodies,  indicated 
by  stimulation,  repression,  decay  and  death. 

It  is  reasonable  to  offer  a  working  h^-pothesis  at  this  stage  of  our 
study,  based  upon  grounds  consistent  with  our  limited  knowledge. 

It  seems  reasonable  to  think  that  the  orderly  growth  and  life  of  a 
cell  is  due  to  a  balance  of  its  electric  charges,  positive  and  negative 
existing  in  each  cell.  \Mien  we  find  a  small  tumor  composed  of  an  over- 
growth of  cells  normal  to  the  part,  we  must  admit  that  some  force  has 
gone  out  of  or  entered  into  its  life  which  has  caused  the  disordered 
growth.  Its  balance  has  been  disturbed.  If,  at  this  stage,  we  supply  it 
with  electrons,  of  one  or  another  kind,  and  see  a  rapid  retiu-n  to  normal 
growth,  there  can  be  btit  one  logical  conclusion,  namely,  we  have 
supplied  the  needed  force  which  was  lost.  Just  at  this  point  we  face  the 
discovery  that  a  shower  of  negative  electrons  freshly  liberated  from 
radium  wUl  cause  a  stimting  of  cell  growth.  Facts  which  will  be  demon- 
strated and  illustrated  further  on  are  these:  Growth  composed  of 
overgrown  masses  of  cells,  return  to  orderly  growth  permanently, 
when  given  the  exact  dosage  of  negative  electrons  are  shot  into  them. 
Growths  to  which  too  much  is  supplied,  undergo  atrophy,  and,  if  exces- 
sively oversupplied,  undergo  death.  We  may  assume,  therefore, 
that  the  dosage  must  correspond  with  the  loss.  We  are  thus  coming 
closer  and  closer  to  the  unfolding  of  one  of  the  puzzling  problems  of 
life,  viz.:  ^Miat  is  inherent  in  the  nucleus  of  every  cell  that  causes  its 
stability?  In  the  cosmos  we  turn  to  students  of  geology,  zoology  and 
biology  to  learn  what  new  thoughts  have  been  evolved  to  elucidate  a 
better  understanding  of  the  origin  of  life  on  the  earth.  Definite  propo- 
sitions, based  on  fact,  have  been  recently  set  forth  by  Prof.  H.  F. 
Osborne  in  an  address  before  the  National  Academy  of  Science.  The 
ripe  thought  of  scientists  turns  to  chemistry  to  pro^•ide  the  substance 
and  framework  to  explain  this  earhest  protoplasmic  development  after 


216  EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 

the  earth  crust  had  cooled,  and  water  and  rock  disintegration,  with 
nitrogen,  carbon  and  oxygen,  gave  material  to  form  corporate  material 
for  electric  stimulation  to  vitalize.  These  electrons  originated  perhaps 
from  friction  of  elements,  from  atmospheric  discharges,  or,  who  can 
say,  radium  latent  in  the  earth,  or  electrons  shot  through  space. 

It  is  a  little  surprising  to  see  the  trend  of  scientific  thought  toward 
electricity  in  recognizing  the  probable  vitalizing  life  force.  It  lends 
much  weight  to  the  growing  recognition  of  the  latent  force  residing 
in  radium  or  issuing  from  the  roentgen  tube  which  is  counted  only  in 
terms  of  electrons. 

It  is  no  flight  of  fancy  to  regard  the  force  in  radium  as  incorporated 
life  or  the  electrons  as  imprisoned  life  released.  The  pathologist  then 
must  take  his  cue  from  the  scientist  and  accept  the  view  that  proto- 
plasmic matter  is  endowed  with  one  vitalizing  actuating  force,  viz.: 
electricity.  After  its  initiation,  matter  thus  endowed  proceeds  on  its 
career  of  more  and  more  complicated  development  and  combinations 
until  infinitely  complex  beings  like  the  human  body  are  developed. 
In  such  complex  machinery,  however,  there  remains  the  solitary  force 
behind  the  life  of  every  component  cell. 

In  disordered  states  this  has  been  shown  by  the  elaborate  study  of 
Lazarus  Barlow,  who  demonstrated  a  measurable  amount  of  radio- 
activity in  the  structure  of  cancer  of  the  gall-bladder  with  gall-stones. 
This  is  not  to  say  that  radium  is  present,  but  a  Hberation  of  negative 
electrons  due  to  cellular  activity  and  disordered  growth. 

We  may  now  turn  to  the  first  questions  in  this  paper,  and  consider 
what  constitute  the  essential  characteristics  of  malignant  disease.  The 
grouping  of  enormous  myriads  of  cells  that  form  a  complex  human 
body,  requires  a  harmonious  interaction  which  staggers  the  imagin- 
ation, but  appeals  to  reason  as  essential.  It  is  the  lack  of  harmonious 
action  that  shows  in  the  development  of  any  and  every  curious  growth, 
to  which  we  give  the  name  of  tumor,  whether  it  be  a  papilloma  or  horny 
excrescence  of  the  skin  or  epithelioma,  sarcoma,  cancer,  fibroma  or 
myomatous  tumor.  They  are  one  and  all,  altered  cell  growths,  exag- 
gerating their  normal  activity,  and  representing  a  disorderly  unbal- 
anced action,  out  of  harmony  with  the  rest  of  the  system.  It  is  as  if 
a  patch  of  grass  on  an  even  lawn  began  to  grow  luxuriantly  and  out  of 
keeping  with  the  rest  of  the  lawn,  but  it  is  still  healthy  grass.  It  is 
a  literary  error  to  speak  of  "diseased"  tissue  when  we  speak  of  tumor 
structure.  While  this  word  may  be  rightly  applied  to  tissues  attacked 
by  parasitic  infective  destructive  agents,  calling  the  structures  "dis- 
eased" as  wc  would  a  tree  attacked  by  "blight,"  it  is  quite  an  error  to 
apply  the  word  to  tumors,  even  though  they  may  be  in  the  end  destruc- 
tive. More  properly  we  should  look  upon  the  mass  of  overgrown 
cells  which  from  habit  we  call  tumors,  as  aggregations  of  cells  which 
are  enjoying  the  excessive  freedom  of  growth,  an  ecstasy  of  joy  and 
growth,  such  as  comes  to  an  imprisoned  city  scholar  set  free  in  vacation 
spirit.  The  riotous  overgrowth  of  cells  normal  to  the  site  of  their 
growth,  constitutes  a  tumor  or  colony  of  healthy  cells,  which  have  lost 


EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 


217 


their  balance  or  equilibrium  in  their  relations  to  their  neighbors.  In  the 
ultimate  outcome  of  this  disorderly  growth,  the  result  is  what  may  be 
called  a  diseased  condition  as  compared  with  orderly,  systematic  com- 
munity growth  in  the  complex  system  of  the  body.  That  word  "dis- 
ease "  applied  to  them  only  refers  to  the  incidental  suicidal  action  of  the 


Fig.  12. — Extensive  warty  growth  on  vocal  cords  before  cure  by  one  radium  treatment. 

cell  life,  because  it  depends  on  nutrition  supplied  by  the  whole  living 
organism,  which  its  very  overgrowth  crowds  out,  so  that  death  follows 
in  that  colony  group  and  mars  the  health  of  the  whole. 


Fig.  13. 


-Perfect  restoration  of  vocal  cords.    Return  of  fine  singing  voice  continuing 
eight  years  afterward. 


Malignant  cells  have  no  characteristics  to  distinguish  them  from 
non-malignant  tumor  cells,  either  microscopically,  physically,  chemic- 
ally, or  in  responding  to  radiant  energy.  It  is  fair  to  say  that  certain 
groupings  of  cells  are  found  in  advanced  malignancy,  and  that  proto- 
plasmic nuclei  show  more  active  mitoses  indicating  rapid  growth,  but 


218 


EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 


in  no  particular  do  individual  cells  show  anomalous  character,  or 
refuse  to  respond  to  agents  like  electrons  of  radium  and  roentgen  ray. 
It  is  true  that  their  successful  application  is  full  of  difficulty,  still  to  be 
overcome,  but  their  efficiency  in  even  so  slight  a  degree  encourages  the 
belief  in  ultimate  advancement. 

Enough  basis  for  understanding  of  the  action  of  electrons  on  all 
cell  tumors  is  found  in  the  simpler  forms,  illustrated  by  papilloma  and 
myeloids  to  choose  only  two  out  of  many  varieties.  A  wart,  or  massive 
overgrowth  of  cells  of  either  the  papillary  layer  of  the  skin  or  of  the 
delicate  layer  of  mucous  membrane  of  the  vocal  cords,  is  identically 
the  same  type  of  tumor.  If  it  is  played  upon  by  rays  of  radium  for  a 
few  minutes  it  slowly  disappears  and  leaves  no  traces  of  its  existence. 
The  same  electrons  have  played  upon  the  healthy  cells  about  it  but 
only  the  weak  overgrown  structure  has  changed. 


A  B 

Fig.  14. — A,  destructive  myeloid  sarcoma.  B,  condition  of  jaw  fourteen  years 
after  radium  cure.  Jaw-bone  restored  to  normal  form  and  great  strength,  teeth  solidly 
embedded. 


If  an  excessive  treatment  has  been  given  even  the  healthy  growing 
cells  are  altered  and  a  slight  scar  results.  Otherwise  nothing  is  dam- 
aged. To  illustrate,  I  will  cite  the  case  of  a  young  girl  with  beautiful 
singing  voice,  which  first  became  husky,  then  was  lost  and  finally  left 
her  with  serious  obstruction  to  breathing  from  growth  of  warts  over 
two-thirds  of  her  vocal  cords  (Fig.  12).  Radium  was  applied  for 
thirty  minutes.  Three  months  later,  the  warts  were  entirely  gone  and 
her  voice  restored.  Her  singing  power  returned  later  and  was  even 
sweeter  than  ever.  Five  years  later  this  perfect  condition  continued 
(Fig.  13).  Thus  exact  dosage  corrected  erroneous  growth,  without 
damage  to  normal  cells.  As  a  second  illustration,  I  will  cite  a  case  of 
myeloid  tumor  of  the  lower  jaw,  cured  by  radium  and  followed  by 
complete  restoration  of  the  bone,  a  result  never  previously  obtained  by 


EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE       219 

surgery.  A  lad  of  seventeen  years,  had  a  soft  tumor  on  the  left  side  of 
his  lower  jaw,  absorbing  the  entire  bone  except  a  thin  strip  on  one  edge. 
The  swelling  was  several  times  the  natural  thickness  of  the  bone,  and 
three  teeth  were  loosely  held  in  it  ready  to  drop  out  (Figs.  14  and  15). 
The  tumor  was  treated  by  radium  only.  In  a  few  weeks  it  became 
gritty  throughout  with  newly  regenerated  bone.  The  tumor  shrank 
rapidly.  New  bone  reformed.  The  teeth  became  solid  in  their  beds 
and  every  trace  of  tumor  disappeared.  The  jaw-bone  took  on  the 
identical  shape  of  its  original  contour,  and  today,  after  thirteen  years, 
it  is  as  solid  and  perfect  as  a  normal  jaw-bone. 


Fig.   15. — Thirteen  years  after  treatment. 

What  answer  can  be  made  to  the  claim  that  here  we  see  the  alterative 
action  of  electrons  reversing  the  disordered  growth  of  marrow  cells,  of 
the  bone,  which  in  their  riotous  action  were  in  line  of  destruction  of  the 
jaw  and  of  the  life  of  the  man,  if  unchecked.  Whether  pathologists 
choose  to  class  myeloid  tumors  as  "malignant"  matters  little,  for  in 
their  progress  they  were  destructive  to  human  life,  and  in  that  intent 
malignant.  The  same  type  of  tumor  in  every  part  of  the  body  yields 
in  similar  fashion.  A  dozen  patients  with  pure  myeloid  growths  have 
shown  identical  curative  action  of  radium.  Tumors  in  the  lower  and 
upper  jaws,  in  the  humerus,  in  the  sternum,  in  the  sacrum,  in  the  tibia. 
The  same  alterative  and  curative  action  has  been  demonstrated  to 
follow  judicious  use  of  the  roentgen  tube  electrons  by  Dr.  Pfahler,  of 
Philadelphia. 


220 


EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 


The  cure  of  epithelial  tumors  by  radium,  notably  the  disfiguring 
and  destructive  t^^pe  of  so-called  skin  cancers  of  the  face,  is  universally 
admitted. 


.2  ^ 

a  § 

a  o 


ft  S 

P    c3 


It  is  no  small  testimony  to  its  usefulness  in  surgery,  but  it  is  a 
greater  testimony  to  its  unique  action  as  a  therapeutic  agent.  Hereto- 
fore surgeons  have  not  been  able  to  cure  this  disease.  They  have  cut 
it  out  or  destroyed  it  by  caustic  acids  or  by  cautery.    Thereby  they 


EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE       221 

have  cured  the  patient,  but  they  have  not  cured  the  disease.  They 
have  only  removed  it.  This  new  agent  supplies  the  tumor  with  a  force 
which  works  within  itself  and  causes  it  to  remove  itself,  if  we  may  so 


Fig.  17. — Same  patient  as  represented  in  Fig.  16,  showing  permanence  of  cure  by- 
radium  after  thirteen  years. 

speak.    Not  only  that,  but  if  the  correct  dosage  of  electrons  has  been 
supplied,  the  growth  never  comes  back.    Witness  the  case  of  destruc- 


FiGS.  18  and  19. — Epithelial  cancer,  had  been  burned  out  by  caustic  pastes  and 
acids  for  several  years  and  recurred.  Received  one  radium  treatment  only.  Fig.  18 
before  treatment,  Fig.  19  after  nine  years,  soft  scar. 

tive  epithelioma  of  the  face,  cured  by  radium,  in  five  weeks  after  many 
years'  growth.  The  small,  smooth  scar  remains  without  return  of 
trouble  after  thirteen  years    (Figs.  16,  17,  18  and  19)  or,  the  case 


222  EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 

of  epithelial  cancer  behind  the  ear,  cured  in  six  weeks  and  remaining 
absolutely  perfect  nine  years  later.  Or,  the  case  of  epithelial  tumor  of 
the  lower  eyelid,  cured  in  eight  weeks  and  remaining  cured  nine  years 


a  ^ 


c  -o 


c  o 


later.  Serious  consideration  must  be  given  to  one  phase  of  this  case, 
illustrating  clearly  what  may  be  claimed  as  a  "specific"  action  of 
radium,  that  is,  of  a  khid  unlike  that  of  any  other  agent.    Here  the 


EFFICIEXCY  OF  RADIUM  IX  MALIGXANT  DISEASE       223 

lower  eyelid  was  entirely  lost,  in  a  tumor  covering  more  than  half  its 
length.  The  structures  of  the  lid  were  engulfed  in  the  growth  beyond 
identification.  The  tumor  was  heaped  up  on  the  skin,  it  mounted  up 
aboA'e  the  edge  of  the  lid  and  grew  inside  the  lid  as  upon  the  outside. 
After  brief  radium  treatment,  shrmkage  rapidly  ensued,  the  lid  was 
evolved  out  of  the  conglomerate  mass  of  cells  and  in  eight  weeks  a 
normal  shaped  eyelid  was  self-restored,  to  speak  exactly.  Even  the 
skin  took  on  normal  appearance.  The  edges  of  the  lid  were  sharp,  the 
mucous  membrane  was  smooth,  the  eyelashes  grew  in  again  (Fig.  20). 
Out  of  the  enormous  mass  of  overgrown  cells  of  the  tumor,  the  original 
ones  which  constituted  the  eyelid  and  skin  were  reassembled  and  for 
nine  years  after,  no  one  could  tell  on  which  eyelid  the  tmnor  had  been. 


Fig.  21. — Round-cell    sarcoma    of    the         Fig.   22. —  Same    case    as    in    Fig.    21. 
skull.     Complete  absorption  of  bone  out-  Cured  by  radium, 

lined  by  iodine. 

One  must  evolve  some  theory  to  account  for  this  extraordinary  over- 
growth of  cells,  which  retreated,  or  melted  away,  like  fog  before  the  sun, 
under  radium  rays'.  Were  they  the  product  of  growth  of  a  micro- 
scopically invisible  network  of  intercellular  cells  so  to  speak,  which 
overwhehned  the  native  ones,  forming  the  lid,  and  when  in  retreat 
left  the  original  ones  unharmed  by  the  electrons  which  affected  the  new 
growth?  Or,  were  they  simply  a  hA^iertrophic  development  from 
excited  growth  of  lifelong  cells  of  the  part,  throwing  off  a  generation 
of  tender  new  cells  of  their  own  kmd,  which  could  not  withstand  the 
bombardment  of  radium  electrons.  In  either  case  such  t^'pes  point 
the  way  to  a  better  appreciation  that  we  have  to  reckon  wdth  a  new 
force  in  therapeutics  from  which  more  may  be  expected. 
There  are  hundreds,  yes,  thousands,  of  cases  similar  to  these  already 


224 


EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 


credited  to  the  alterative  action  of  electrons,  and  it  may  rightly  be 
called  a  specific  and  unique  action.  Regardless  of  futile  discussions 
as  to  what  types  may  or  may  not  be  styled  malignant,  there  are  others 
that  must  be  credited  with  specific  cure  by  electrons  which  no  other 
surgical  method  can  touch  (Figs.  21  and  22). 

As  an  example,  a  round-celled  sarcoma  of  the  skull  of  a  man  of 
forty-five  years  had  eaten  through  the  parietal  bone  to  an  area  of  4  x  3 
inches.  This  soft  vascular  growth  rested  on  the  dura  and  elevated  the 
skin,  comprising  a  depth  of  2  inches  of  tumor  tissue.  Enough  was 
removed  for  microscopic  examination  and  radium  tubes  inserted 
throughout  the  mass,  lying  parallel  to  the  dura.  The^tumor  soon 
disappeared  and  after  four  years  has  never  returned.  The  patient  has 
maintained  perfect  health  and  w^orking  power.  Photographs  before 
and  after  show  clearly.  The  type  of  round-cell  sarcoma  is  not  the  most 
common,  but  seems  to  yield  with  peculiar  facility,  while  the  spindle 


Fig.  23 


cell  is  intensely  resistant.  Periosteal  tumors,  mostly  of  spindle  cell 
with  some  myeloid  cells  scattered  throughout  are  not  yet  amenable  to 
cure  by  radium;  nor  are  the  gliomas,  especially  of  the  nervous  tissue. 
A  few  attempts  have  been,  as  yet,  wholly  ineffectual.  There  are  certain 
structures  which  we  are  still  compelled  to  excise,  inasmuch  as  either 
we  do  not  know  how  to  use  the  electrons  for  them  or  they  must  be 
corrected  by  some  yet  unknown  remedy  (Fig.  23). 

Among  these  are  the  squamous-celled  epitheliomas  of  the  skin,  which 
usually,  though  not  always,  present  a  character  clinically  different 
from  the  basal-cell  type.  If  one  can  discern  one  from  the  other,  the 
squamous-cell  type  must  be  eradicated  by  caustics,  cautery  or  the 
knife.  This  is  not  wholly  true,  however,  of  the  cancer  most  commonly 
known  as  malignant.  One  must  study  the  effect  of  radium  electrons  on 
relatively  small  areas  of  recurrence,  after  removal  of  typical  scirrhus 
cancer,  such  as  seen  in  mammary  cases,  to  know  definitely  that  the 
same  specific  action  can  easily  be  demonstrated  there  as  in  simple 


EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE       225 

epitheliomas.  It  is  futile,  to  assert  that  radium  is  ineffectual  because 
one  is  called  upon  to  excise  a  large,  or  long-standing  mass  of  cancer. 
If  a  small  beginning  of  one,  or  a  part  of  a  recurrent  cuirasse  carcinoma 
yields  definite  cure,  its  removal  is  quite  as  triumphant  if  radium  or 
the  scalpel  brings  it  about. 

It  has  long  been  proved,  that  in  the  early  recurrences  of  the  skin 
after  mammary  removal  for  cancer,  radium  can  cause  a  complete 


Fig.  24 


melting  away  of  moderate  invasions.  It  only  needed  the  greater 
efficiency  of  the  Coolidge  x-ray  tube,  in  demonstrating  the  rapid 
destruction  of  larger  cancer  masses,  to  endorse  the  work  of  radium 
in  similar  lines.  Technically  one  is  more  difficult  than  the  other,  but 
the  principle  of  action  by  electronic  discharge  is  the  same.    As  an 


Ju^rular  vein         Clavicle 
Fig.  25 


illustration  of  radium  action  alone  in  combating  the  disease,  let  me  cite 
the  case  of  a  lady  of  seventy-five  years,  seriously  weakened  and  poisoned 
by  absorption  from  an  ulcerative  and  bleeding  cancer  of  the  breast. 
Six  short,  painless  applications  of  radium  caused  a  rapid  healing  and 
shrinking  of  the  masses,  until  a  small  group  of  inert  fibrous  remnants 
about  the  smooth  scar  remained  unchanged  for  two  years.  The  patient 
died  suddenly  of  acute  nephritis,  entirely  unrelated  to  the  disease. 


VOL.  I — 15 


226       EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 

One  of  the  principles  best  illustrating  the  efficient  use  of  radium  in 
tApical  cases  of  clinical  cancer  was  enumerated  by  Wickham  in  the 
early  years  of  his  work,  by  which  he  demonstrated  that  if  the  surgeon 
removed  all  possible  cancer  from  a  mass  and  left  only  a  thin  shell,  this 
remnant  could  be  efficiently  controlled,  for  a  time  at  least,  by  radium, 
but  that  it  was  useless  and  hazardous  to  treat  masses  by  exerting  the 
destructive  agency  of  radium.  This  I  have  demonstrated  by  such  cases 
as  the  following: 

A  lady  whose  breast  showed  a  small  topical  scirrhous  nodule,  the 
size  of  a  prune  stone,  permitted  excision  only  under  cocain.  It  was  not 
at  all  wide  of  the  disease  from  a  surgical  point  of  view  and  recurrence 
would  have  been  speedy  had  I  not  given  a  good  radium  insertion 
embedded  in  the  operative  field.  Three  years  have  elapsed  and  no 
trace  of  hardness  shows  in  the  soft  scar. 


Fig.  26. — Perfect  health  eight  j-ears  later.     Small  flat  remnant  left  at  operation  now 

dormant. 

Again,  a  lady  of  forty  years  presented  a  hard  growth  above  the  left 
clavicle  near  the  sternoclavicular  tendon  (Fig.  24). 

It  was  close  beneath  the  skin  and  not  very  mo\eable.  At  operation  a 
dense  cancer  mass  was  removed  with  great  difficulty  (Figs.  24  to  26). 
It  lay  between  the  jugular  and  carotid  at  their  points  of  origin.  The 
former  was  carefully  dissected  off  but  the  growth  adhered  so  tightly 
to  the  common  carotid  artery  for  an  inch  away  from  the  innominate 
that  a  thin  layer  of  tumor  was  necessarily  left  attached  to  it.  The 
wound  was  closed  except  a  sinus  where  a  strong  tube  of  radium  was 
left  resting  against  the  shell  of  the  cancer.  After  a  few  hours  this  v/as 
removed  and  the  wound  healed.  Nine  years  have  gone  by  and  no  trace 
of  trouble  has  shown.  Examination  of  the  tumor  showed  it  to  be 
cancer.    Its  size  was  that  of  a  half  egg. 

Again,  on  two  occasions  I  ha^'e  excised  carcinomatous  masses  of  the 
lower  parotid  gland  and  implanted  radium  tubes  in  the  bed  of  the 
excised  mass,  knowing  that  speedy  recurrence  was  inevitable  without 
that  sequel.    In  both  cases  more  than  four  years  have  gone  by  and  no 


EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE       227 

trace  of  trouble  can  be  felt  in  the  soft  cicatrix.  In  other  cases  of  parotid 
tumors  the  more  common  mixed  sarcomas,  the  arrest  of  growth  has 
been  commensurate  with  the  amount  of  radium  used,  but  slowly  the 
recurrences  have  come,  yet  each  time  one  feels  that  a  heavier  dosage 
will  make  an  end  of  the  local  residue  which  the  surgeon  cannot  see  but 
only  suspect.  In  all  radium  work  diseases  involving  the  gland  struc- 
tures, cutaneous,  lymphatic  or  salivary,  seem  to  yield  better  than  those 
entering  areolar  or  muscular  structures. 

Great  discouragement  necessarily  follows  all  pioneer  work  in  new 
fields,  because,  attempts  must  be  made  to  test  apparently  hopeless 
trails  which  must  be  abandoned  temporarily,  only  to  be  taken  up  again 
and  again  as  new  methods  prevail.    In  this  line  of  pursuit,  hundreds 


Fig.   27. — Cancer  of  tongue. 

of  advanced  cases  of  cancer  have  been  submitted  to  test,  sometimes 
mild,  sometimes  heroic.  Discredit  and  abuse  have  been  undeservedly 
received;  Out  of  all,  however,  it  is  fair  to  say  that  in  grave  cases  much 
that  has  been  helpful  has  resulted,  and  in  the  early  cancer  cases,  appar- 
ent cure  results.  More  cannot  be  said  to  the  credit  of  surgery  by 
cutting  methods. 

Let  me  speak  in  order  of  types  of  cancer  in  places  difficult  of  treat- 
ment; in  the  alimentary  tract;  cancer  of  the  tongue;  mouth;  pharynx; 
esophagus;  stomach;  intestines;  rectum.  Every  surgeon  knows  that 
leukoplakia,  a  hypertrophic  white  growth  of  the  mouth  and  tongue, 
cannot  be  cured  by  any  method  except  radium,  and  that,  only  by  most 
judicious  use.  Also,  he  knows  that  when  it  has  become  ulcerated  it 
becomes  cancerous  and  must  be  cut  out  extensively.  It  now  seems  that 
such  early  growths  yield  to  radium  and  stay  cured,  at  least  for  such 
time  as  radium  has  been  available.    Again,  every  surgeon  knows  that 


228       EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 

excision  of  a  half  tongue  for  typical  cancer  with  lymphatic  extirpation 
is  almost  sure  to  be  followed  by  recurrence  (Fig.  27).  Some  recent 
work  by  such  surgery  supplemented  by  radiumization  of  the  edges 
without  recurrence  up  to  more  than  four  years,  suggests  a  happier 
issue  than  plain  surgery  has  to  offer. 

Cancer  of  the  tonsil  and  pharynx  in  advanced  conditions,  has  little 
to  hope  from  surgery  alone,  and  but  little  more  from  radium.  This  is 
due  partly  to  the  difficulty  of  exact  application,  where  salivation, 
choking,  pain  and  deglutition  add  to  the  discouragement  of  patient 
and  surgeon,  partly  to  the  high  vascular  and  lymphatic  supply  of  the 
part.  Few  good  effects  of  radium  are  seen.  In  the  nasopharynx  an 
occasional  control  of  the  disease  can  be  accomplished,  owing  to  the 
facility  of  continued  application  of  radium  applications.  In  massive 
cancers  of  the  tongue  itself  with  foul  ulceration,  one  sometimes  can 
cause  rapid  reduction  of  the  mass  and  get  the  sore  almost  healed,  but 
sooner  or  later  the  growth  takes  on  its  wonted  activity.  The  field  is 
not  a  hopeless  one,  for  further  study  of  radio-active  agents.  The  lip 
cancers  are  not  yet  legitimate  material  for  cure  by  radium,  though 
some  superficial  types  have  been  cured.  It  is  far  better  for  the  patient 
to  have  wide  excision  which  usually  insures  future  immunity. 

In  the  esophagus,  a  cancer  usually  takes  the  form  of  a  cylindrical 
development,  with  thickening  on  one  side  or  the  other,  to  a  mass  of 
half  an  inch  or  more.  This  is  not  as  yet  amenable  to  control  by  radium, 
although  one  would  think  the  opportunity  for  exact  central  application 
of  a  radium  tube  would  permit  efficient  action,  which  is  true  as  far  as 
radiumizing  the  mass  goes.  There  are  factors  of  peculiar  seriousness 
in  the  central  mediastinum  which  baffle  the  operator.  One  must  aim 
at  the  destruction  of  the  massive  cylinder.  This  means  ulceration, 
absorption,  toxemia  and  peril  to  an  already  weak  subject.  The  efficient 
dosage  also  implies  severe  radiant  effect  on  the  cardiac  nervous  system, 
and  finally  if  the  erosion  and  destruction  of  the  cancer  mass  takes  place, 
one  must  expect  hemorrhage,  pain,  perforation  and  abscess  from  acts 
of  deglutition,  which  are  an  unwarranted  jeopardy.  On  the  whole, 
therefore,  the  use  of  radium  in  esophageal  cancer,  mostly  tried  in 
advanced  cases  thus  far,  has  nothing  to  recommend  it. 

The  same  may  be  said  of  cancer  of  the  stomach  and  pylorus.  Never- 
theless, while  one  does  not  look  for  a  cure,  in  these  cases,  it  is  possible 
in  a  few  selected  types  to  control  growth  and  repress  hemorrhage  if 
one  can  have  access  to  the  disease  through  a  gastrostomy  sinus.  This 
means  technically  that  an  internal  and  external  use  of  radium  in 
quantity  sufficient  to  filter  out  the  soft  rays  with  lead,  and  "cross  fire" 
the  mass  if  accessible  enough.  It  is  fair  to  say,  however,  that  here  one 
uses  mostly  gamma  radiation,  which  may  probably  be  more  penetrat- 
ingly and  efficiently  obtained  from  an  a:-ray  tube,  or,  that  without, 
and  radium  within. 

In  malignant  disease  of  the  rectum  we  have  several  varieties  known 
to  every  surgeon,  and  many  stages  of  each  variety.  It  is  a  fairly  good 
field  for  study  of  radium.    Let  us  first  premise  that  the  best  surgical 


EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE       229 

treatment  stands  today  as  (1)  preliminary  colostomy;  (2)  ^where 
feasible,  a  well  considered  surgical  extirpation  of  part  or  of  the  whole 
rectum  with  the  disease.  The  surgeon  who  wishes  to  do  his  full  duty 
to  his  patient  then  has  to  consider  whether  radium  offers  any  additional 
help.  My  judgment  is  that  it  does,  if  used  discreetly,  which  means 
that  our  first  duty  is  to  advise  colostomy  as  early  as  possible.  It  will 
have  to  come  some  time.  It  removes  the  incessant  irritation  of  the 
growth  and  arrests  its  rapid  progress.  If  its  removal  is  not  possible 
then  we  use  radium,  varying  the  amount  and  method  according  to 
conditions.  The  immediate  effect  is  usually  to  check  hemorrhage  by 
vascular  occlusion  of  the  surface  of  the  growth,  and  incidentally 
usually  to  relieve  severe  pain.  More  constant  even  than  these  results 
there  is  ahnost  uniformly  a  speedy  gain  in  color,  a  loss  of  the  cachexia, 
whether  it  be  anemic  or  toxemic,  and  a  diminished  foul  secretion,  from 
the  absorption  of  which  some  of  the  toxemia  may  have  resulted. 

When  one  reviews  a  large  surgical  experience  of  forty  years  in  this 
field  and  makes  due  allowance  for  the  natural  improvement  follow- 
ing the  simple,  highly  valued,  colostomy,  he  still  finds  prolongation  of 
life  and  relative  relief  from  pain  and  hemorrhage  with  continual 
increase  in  color,  to  the  credit  of  radium.  The  expected  prolongation 
of  life  may  be  therefore  estimated  about  double,  that  is  to  say,  if  when 
seen  first,  two  years  may  be  rated  as  the  patient's  hope,  it  may  be  four 
years  if  radium  be  used. 

Experience  shows  that  the  best  method  of  using  radium,  here  as 
elsewhere,  is  to  give  as  much  as  the  part  will  stand  at  one  or  two 
seances,  and  then  dismiss  the  patient  for  two  months  at  least.  In  this 
way  only  can  one  estimate  the  gain.  Usually  there  ensues  stenosis  of 
the  lumen  of  the  bowel  as  atrophy  of  the  mass  takes  place.  One  must 
not  deceive  himself  by  occlusion  from  progress  of  the  growth  in  some 
cases. 

In  uterine  cancer  much  the  same  record  prevails  today  as  in  rectal, 
except  that  the  general  trend  is  better.  Both  tj^es  are  helped  by 
radium  when  there  is  a  marked  adenocarcinoma,  and  in  its  early  stage 
when  the  cervix  uteri  has  erosion  and  cellular  ingrowth  into  the  sub- 
mucous layer,  this  can  be  destroyed  by  radium.  One  such  case  only  in 
my  experience  has  endured  with  no  return  of  disease  twelve  years.  In 
other  cases  where  intense  radiumization  has  been  tried  out  the  destruc- 
tion of  malignant  cells  has  gone  out  into  the  extra-uterine  tissue  and 
made  inoperable  cases  operable.  In  the  face  of  universal  acknowledg- 
ment that  such  cases  invariably  return  with  bad  recurrences  (usually 
early),  the  hope  of  cure  of  early  uterine  cancer  lies  in  the  use  of  radium, 
or  some  powerful  destructive  agent  (caustic  or  cautery),  with  subse- 
quent operation. 

When  inoperable  recurrences  occur  in  the  vaginal  scar,  usually  in  the 
vault,  and  spreading  into  the  broad  ligaments,  the  liberal  use  of  filtered 
radium  will  at  times  cause  a  striking  retrograde  of  the  recurrence.  In 
one  case,  sent  to  me  with  extensive  and  inoperable  recurrence,  after 
complete  hysterectomy  for  cancer,  by  Dr.  Robert  T.  Morris,  followed 


230       EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 

by  a  second  apparently  thorough  operation  for  proved  secondary  cancer, 
I  was  able  to  induce  so  perfect  a  disappearance  of  all  the  tNpical  mass 
spread  through  the  scar  and  broad  ligaments,  that  for  two  years  nothing 
could  be  felt  and  the  i)atient  maintained  perfect  health.  During  the 
third  year  a  nodule  again  appeared  and  slowly  extended.  Again  the 
radium  retarded  its  gro^Alh,  but  slow  extension  exhausted  the  patient 
after  four  years.  In  most  such  cases  the  utmost  I  have  been  able  to 
accomplish  (having  due  regard  to  uncomfortable  vaginal  burns)  has 
been  to  retard  growth,  check  hemorrhage,  reduce  the  distressing  foul 
discharge  and  improve  color. 

The  cervix  occasionally  shows  fungating  cancer  protruding  massively 
into  the  vagina.  This  type  is  especially  amenable  to  curetting  away, 
until  a  hard  base  is  left,  which  is  given  a  heavy  radiumization.  One 
such  case  in  my  hands  li^•ed  many  years  and  died  from  other  causes  with 
no  recurrence.  Knowledge  of  its  full  value  in  these  cases  must  await 
some  years  more  of  study  by  those  who  have  enough  experience  with 
surgery  as  with  radium,  to  speak  with  authority.  It  would  be  useless 
to  pursue  the  theme  further  to  speak  of  the  multiple  and  efficient  uses 
of  radium  in  other  parts. 

The  subject  is  by  no.means  ready  for  encyclopedic  conclusions.  The 
field  is  open  for  progress  in  both  efficient  and  wider  usefulness,  and  for 
technical  miprovement  in  its  applications.  It  seems,  at  present,  that 
its  greatest  benefit  comes  from  using,  at  will,  the  Beta  rays,  mixed  with 
gamma  as  given  oft'  from  applicators  and  tubes,  or,  in  suitable  cases,  by 
enveloping  it  with  metal  of  varying  thickness  to  utilize  the  penetrating 
gamma  rays  alone  with  no  risk  of  burning  the  skin  or  mucous  mem- 
brane. In  both  cases,  a  cross-fire  attack  upon  the  disease  by  an 
opposing  radium  applicator  as  correctly  credited  to  AYickman,  is 
without  question  the  surest  way  to  promote  its  good  work. 

It  seems  to  the  author  that  malignant  cells  are  not  inherently  differ- 
ent in  their  nature  from  other  living  cells.  They  have  a  different 
coefficient  of  resistance,  so  have  spindle  cells,  and  others,  but  that  they 
do  respond  to  radium  has  been  proved,  and  can  be  demonstrated  in 
recurrent  nodes  under  the  skin  in  breast  cancer  cases. 

Fig.  28,  made  for  me  by  Dr.  F.  C.  Wood,  demonstrates  clearly  the 
sphere  of  influence,  though  it  be  small,  which  a  tube  of  radium  has 
when  laid  on  the  skin  over  such  a  nodule.  Technical  methods  remain 
undeveloped,  but  the  efficiency  of  radium  as  a  new  force  must  be 
reckoned  with  in  the  future  of  surgery. 

Technical  Application. — Xo  good  result  can  be  expected  from  the 
use  of  radium  without  earnest  study  on  the  part  of  the  operator.  It 
has  long  been  the  expressed  opinion  of  the  author  that  no  one  who 
ventures  to  use  it  in  practice  should  do  so  without  first  testing  his 
particular  specimen  or  specimens  upon  his  own  skin.  While  there  is 
probably  very  slight  difference  in  idiosyncrasy  of  patients  to  its  action, 
there  is  the  greatest  difference  in  the  working  efficiency  of  each  specimen. 
This  is  due  to  the  fact  that  any  ten  milligrammes  may  differ  in  purity, 
or  in  its  container,  that  is,  it  may  be  sealed  in  a  thin  or  a  thick  glass 


TECHNICAL  APPLICATION 


231 


tube,  or  in  a  tube  of  metal,  or  spread  on  a  metal  plate  (plaque)  em- 
bedded in  varnish  or  enamel.  To  speak  therefore  of  the  number  of 
milligramme-hours  that  may  serA'e  to  produce  a  certain  efficiency  is 
quite  uncertain.  It  is  eAident  that  ten  milligrammes  confined  in  a  very 
small  tube  affects  a  local  area  close  to  it,  while,  when  spread  on  the 
surface  of  a  metal  plaque,  the  size  of  a  quarter  dollar,  its  effective 
radiumization  of  the  same  area  covered  by  the  tube  would  take  longer. 
The  author  has  long  held  that  no  physician  can  so  well  work  with 
his  o^Ti  specimens,  or  understand  so  well  the  working  of  radium,  as 
he  can  when  he  has  first  tried  it  on  himself.  He  may  best  choose  per- 
haps the  inner  side  of  the  calf  of  his  leg  for  this  test.  Let  the  appli- 
cation be  placed  on  the  skin,  at  three  nearby  spots,  for  difterent  periods 
say,  five,  ten,  and  fifteen  minutes  for  very  strong  specimens,  or  twice 


Fig.  28. — Showing  sphere  of  influence  with  dead  cancer  nests.    Recurrent  subcutaneous 
nodule  degenerating  under  one  radium  application. 


that  time  for  weaker  ones.  The  effect  should  begin  to  show  in  ten  days 
as  a  dermatitis;  itching,  burning  and  perhaps  blistering  in  the  following 
ten  days;  subsiding  and  forming  a  dry  crust  during  the  third  ten  days. 
On  the  thirtieth  day  the  crust  falls  from  a  smooth  skin.  This  is  about 
the  usual  effect  desired  to  restore  a  simple  keratosis,  mild  epithelioma 
or  a  wart. 

Having  once  experienced  the  very  definite  results  of  using  his 
specimens  he  never  loses  the  mental  picture  of  its  action,  or  rarely 
misjudges  the  requisite  time  of  application  to  each  patient.  For  the 
greater  number  of  mild  epithelial  lesions,  the  author  prefers  one  or 
two  exposures  near  together,  and  then  gives  the  patient  a  written 
statement  of  what  to  expect  during  the  month  following.  If,  however, 
more  intensive  treatment  is  necessary,  then  cumulative  or  successive 
attacks  are  better,  and  an  interval  of  one  or  two  weeks  between  treat- 
ment works  out  a  better  result.    Thus,  successive  blows  fall  upon  the 


232       EFFICIENCY  OF  RADIUM  IN  MALIGNANT  DISEASE 

disease,  sustaining  a  long  corrective  action,  rather  than  an  intense  and 
destructive  one. 

Any  epithelioma  less  than  one  centimeter  in  thickness  can  be  treated 
by  radium  which  is  not  shielded  by  lead.  The  container  or  applicator 
should  be  covered  by  thin  rubber  sheeting  (dental  dam)  and  by  several 
layers  of  gauze.  If  a  recurrent  cancer  node  or  a  lymph  gland  lies  under 
healthy  sldn,  then  a  lead  shield  must  be  interposed  to  prevent  burning 
the  skin,  while  penetrating  rays  are  efficient  below  it.  For  ordinary 
purposes  thin  sheet  lead,  yV  millimeter  thick  (thickness  of  thick 
writing  paper)  is  adequate.  This  permits  an  hour  exposure,  with  a 
specimen  which  without  lead  would  give  sharp  dermatitis  in  one-third 
that  time.  A  two-hour  exposure  with  Y^,y  more  lead  will  be  more 
efficient  in  deeper  growths.  In  pelvic  recurrent  cancer  in  the  upper 
vaginal  scar,  the  best  results  I  have  seen  were  from  one  hundred  milli- 
grammes or  more  in  tubes,  surrounded  by  yo  millimeters  thickness  of 
lead  for  two  hours.  The  same  amount  in  a  brass  container,  2  mm. 
thick  is  equally  efficient  applied  ten  to  twelve  hours. 

The  best  surface  applicator  now  devised  is  one  in  which  radium  is 
mingled  with  the  least  possible  amount  of  pulverized  glass  and  fused 
at  a  very  high  temperature  into  an  enamel  on  a  metal  button.  By  this 
way  the  maximum  concentration  is  obtained  and  a  surface  of  the 
diameter  of  a  ten-cent  piece  can  be  enamelled  with  25  mg.  of  radium, 
which  would  require  a  disk  the  diameter  of  a  silver  half  dollar  if  made 
with  the  usual  varnish,  which  is  much  more  perishable.  Such  a  con- 
centration in  a  small  disk  has  very  great  advantages.  It  permits  a 
short  application  of  ten  minutes  which  justifies  the  physician  in  devot- 
ing that  amount  of  time  to  concentrated  thought  in  applying  it  with 
extreme  care  exactly  as  he  wishes,  instead  of  strapping  it  upon  the 
patient,  and  finding  in  half  an  hour  that  it  had  slipped  from  its  place, 
or  been  displaced  by  the  patient.  By  its  size,  also,  it  permits  exact 
application  about  the  tongue  and  inside  the  mouth  and  other  cavities. 
This  is  most  essential  in  its  difficult  but  effective  use  in  leukoplakias. 
This  small  25  mg.  enamel  button  I  regard  as  the  finest  working  model 
for  radium  therapy.  It  is  readily  enveloped  in  rubber,  thin  lead  and 
gauze,  clamped  by  its  small  knob  at  the  back  of  the  button  in  the  bite 
of  a  long  clamp,  and  thrust  into  a  narrow  thin  rubber  bag  which  permits 
it  to  be  pushed  against  the  tonsils  or  far  up  in  the  vault  of  the  vagina 
against  a  diseased  cervix  or  cancerous  scar,  and  there  held  with  unrival- 
led precision  during  the  needed  exposure.  Being  carefully  protected 
it  is  never  soiled,  but  if  it  does  become  so,  it  can  be  safely  washed 
without  dissolving  the  radium  from  the  enamel.  In  practice  it  is 
found  that  ten  minutes'  use  of  this  concentrated  enamel  plaque  equals 
thirty  minutes  of  the  same  amount  in  a  varnish  plaque  which  must  be 
of  four  or  five  times  larger  area.  It  has  the  added  advantage  also  of 
being  moved  back  and  forth  over  irregular  surfaces,  as  in  nevus,  or 
skin  lesions,  and  evenly  affecting  the  disease  with  no  scarring  or  spotty 
results.  The  method  of  concentrating  radium  emanation  into  capil- 
lary glass  tubes  which  can  be  inserted  in  thin  metal  needles  and  thrust 


TECHNICAL  APPLICATION  233 

into  tumors  for  penetrating  and  cross-fire  result,  finds  many  uses  and 
some  advantage.  Nevertheless,  tubes  of  stiff  thin  celhiloid  have  been 
successfully  used  by  the  author  for  twelve  years,  to  contain  two  to 
five  glass  tubes  of  radium,  each  holding  25  mg.,  which  he  has  pushed 
into  stab  wounds  in  tumors  to  cross-fire  them  in  every  direction.  These 
superseded  long  experimentation  with  purified  goosequills,  which  offer 
no  resistance  to  the  radium  penetration.  The  celluloid  tubes  are  very 
inexpensive,  four  inches  long,  smaller  than  a  lead  pencil,  and  are  never 
used  twice. 

It  will  be  evident  to  the  reader  that  it  is  impossible  for  an  amateur 
with  only  10  mg.  of  radium  to  do  effective  work.  He  will  only  disap- 
point himself  and  his  patient  and  bring  disrepute  on  this  important  new 
field  of  surgical  endeavor.  It  is  fan-  to  say  also  that  no  one  without  a 
previous  varied  and  large  surgical  experience  can  do  justice  to  com- 
parisons between  the  efficiency  of  radium  and  of  other  well  established 
destructive  remedies.  The  use  of  this  wonderworking  agent  should  be 
left  to  those  who  have  enough  to  study  its  effect  and  whose  clinical 
opportunities  enable  them  to  select  suitable  cases  for  its  use. 


DEEP  KOENTGENTHERAPY. 


By  henry  SCHMITZ,  A.M.,  M.D.,  F.A.C.S. 

RoENTGENTHERApy  of  todav  differs  from  that  of  yesterday  as 
fundamentally  as  sm-gery  of  today  differs  from  that  of  the  era  before 
Lister,  Pasteur  and  Koch. 

The  introduction  of  the  Coolidge  tube,  the  development  of  the 
modern  interrupterless  transformer,  as  first  devised  by  Snook,  of  Phila- 
delphia, and  lastly  the  replacement  of  the  rheostatic  control  with  the 
magnetic  autotransformer  control,  have  contributed  immeasurably  to 
the  development,  efficiency  and  efficacy  of  deep  roentgentherapy. 

The  Coolidge  tube  possesses  simplicity  in  operation,  accuracy  in 
penetration  and  duplication  of  results.  The  modern  interrupterless 
step-up  transformer  with  the  autotransformer  control  gives  us  a  con- 
stantly maintained  voltage  when  tube  current  is  increased. 

The  roentgentherapist  should  understand  the  principles  involved 
in  the  physics  of  roentgenology.  He  should  be  well  informed  in  general 
medicine;  should  understand  the  pathology  of  the  disease  that  he  is 
called  upon  to  treat  and  should  be  familiar  with  the  technical  knowledge 
that  is  approved  by  the  best  authorities  in  the  treatment  of  each  par- 
ticular disease.  He  should  be  familiar  with  the  effects  of  the  roentgen 
rays  on  the  living  cell.  We  can  see  at  a  glance  that  the  mastery  of 
these  requirements  is  no  child's  play  but  means  hard  and  continuous 
work,  and  should  be  associated  with  a  deep  sense  of  responsibility.^ 

THE  COOLIDGE  TUBE. 

The  great  difficulty  in  the  operation  of  the  ordinary  gas  tube  lies  in 
the  irregular  supply  of  electrons  and  the  impossibility  of  their  accurate 
development.  In  therapy  these  obstacles  are  continuously  a  source  of 
worry.  For  as  the  vacuum  of  the  gas  tube  through  the  heating  of  the 
anticathode  becomes  lower  and  lower  on  account  of  the  requirements  of 
prolonged  use,  the  rays  given  off  proportionately  decrease  in  their 
penetrating  power.  It  could  only  partly  be  corrected  by  water- 
cooling  devices,  a  frequent  exchange  of  tubes  and  reducing  the  load  of 
milliamperage  which  necessitated  a  proportional  prolongation  of  the 
time  of  application. 

Wehnelt  and  Richardson  had  found  that  electrons  also  were  emitted 
by  hot  metals.  This  led  to  a  series  of  developments  of  the  roentgen 
tube,  beginning  with  Lilienfeld,  in  December,  1911,  continuing  with 

1  Pfahler,  G.  E. :  Am.  Jour,  of  Roentgenology,  August,  1916,  iii,  404. 

(235) 


236 


DEEP  ROENTGENTHERAPY 


Fiirstenau,  in  x\pril,  1912,  and  culminating  with  Coolidge,  in  December, 
1913.  This  particular  development  of  the  roentgen  tube  has  given  to  us 
the  electron  type  of  tube,  as  first  presented  in  Germany  by  the  Lilien- 
feld  tube,  and  finally  in  this  country  by  the  Coolidge  tube.  These 
developments  have  been  epoch-making,  demonstrating  as  they  did, 
for  the  first  time,  the  possibility  of  transferring  electricity  through 
space  without  the  interposition  of  ponderable  matter.  This  may  be 
said  to  be  one  of  the  most  striking  facts  of  modern  science  (see  Fig.  29) . 


Fig.  29.— Coolidge  tube. 

For  the  proper  operation  of  the  Coolidge  hot  filament  tube  the 
highest  possible  vacuum  must  be  attained,  so  there  might  be  no  source 
of  electrons  except  from  the  hot  filament.  Thus  the  operator  has  per- 
fect control  of  the  number  of  available  electrons  by  simply  changing 
the  auxiliary  current  heating  the  filament,  an  increase  of  this  current 
raising  the  number  of  electrons,  and  vice  versa,  a  decrease  in  the  current 
lowering  the  number.  The  filament  current  in  the  tube  cannot  get 
increased  after  the  supply  of  electrons  is  entirely  utilized,  no  matter 


Fig.  30. — The  anticathode  or  target  of  a  Coolidge  tube. 

how  much  the  voltage  is  raised.  This  maximum  current  is  known  as 
the  saturation  current.  The  Coolidge  tube  will  give  us  accuracy  of 
adjustment,  stability  of  hardness,  possibility  of  exact  duplication  of 
results,  unlimited  life,  great  range  of  flexibility,  absence  of  inverse 
radiation  and  extremely  large  output. 

The  Coolidge  tube  consists  of  a  tube  exhausted  to  a  pressure  of  not 
more  than  a  few  hundredths  of  a  micron  (a  micron  is  0.001  mm.),  in 


THE  COOLIDGE  TUBE 


237 


which  is  supported  the  cathode  so  arranged  that  it  may  be  heated 
electrically;  an  electrically  conducted  cylinder  or  ring  connected  to 
the  heated  cathode  and  so  located  with  reference  to  it  as  to  focus  the 
cathode  rays  on  the  target  and  the  anticathode  or  target,  which  func- 
tions as  an  anode. 


0 

mmfMsB 


.-^^*^ 


Fig.  31. — The  filament  of  a  Coolidge  tube. 


\ 


The  filament  (see  A,  Fig.  30)  which  forms  the  cathode  consists  of  a 
flat,  closely  wound  spiral  of  tungsten  wire.  By  means  of  a  rheostat 
the  heating  current  may  be  varied  from  three  to  five  amperes,  giving 
a  potential  drop  through  the  filament  of  from  4.2  to  10  volts,  with  a 
corresponding  temperature  variation  of  from  1700°  to  2350°  C. 


Fig.  32. — The  filament  current  transformer. 


The  focussing  device  consists  of  a  cylindrical  tube  of  molybdenum 
(see  B,  Fig.  30),  mounted  concentric  with  the  tungsten  filament  and  with 
its  inner  end  projecting  about  0.5  mm.  beyond  the  plane  of  the  latter. 
Besides  acting  as  a  focussing  device  it  also  presents  any  electron  dis- 
charge from  the  back  of  the  cathode. 

The  anticathode  or  target  (Fig.  31),  which  also  serves  as  an  anode. 


238 


DEEP  ROENTGENTHERAPY 


consists  of  a  single  piece  of  wrought  tungsten  (C)  attached  to  a 
molybdenum  rod  (D)  and  supported  by  a  split  iron  tube  (E). 

The  important  characteristics  of  the  Coolidge  tube  are:  (1)  No  dis- 
charge current  through  the  tube  unless  the  filament  is  heated;  (2) 
the  amount  of  discharge  current  is  determined  primarily  by  the  amount 
of  current  passed  through  the  filament;  (3)  the  penetrating  power  of 
the  roentgen  ray  is  determined  by  the  voltage  across  the  tube  terminals; 
(4)  the  starting  and  running  voltages  are  the  same;  (5)  the  allowable 
energy  imput  is  determined  by  the  size  of  the  focal  spot;  (G)  contin- 
uous operation  is  possible  without  change  of  characteristics;  (7)  the 
focal  spot  is  fixed  in  position. 

To  simplify  and  render  more  accurate  the  operating  of  the  Coolidge 
tube,  some  source  of  filament  current  is  needed  which  gives  a  perfectly 
constant  potential.  A  specially  designed  step-up  transformer  has  been 
devised  for  this  purpose  (see  Fig.  4) ,  which  is  connected  with  the  usual 
filament  current  controller.    It  is  the  function  of  the  former  to  make  it 


Fig.  33. — The  filament  current  transformer  control. 


possible  to  deliver  to  the  filament  constant  current,  even  though  the 
line  voltage  may  fluctuate  greatly  and  suddenly.  The  filament  current 
transformer  is  retained  merely  to  provide  the  necessary  insulation 
between  the  filament  circuit  and  the  supply  mains.  The  special 
constant  potential  transformer  has  no  moving  parts  and  no  time  lag. 
It  allows  the  filament  current  to  fluctuate  less  than  1  per  cent.,  when 
the  supply  voltage  varies  25  per  cent.  This  means  that  it  completely 
takes  care  of  the  ordinary  fluctuations  in  the  supply  voltage,  due  to 
causes  external  to  the  roentgen-ray  installations  and  of  the  sudden 
drop  caused  by  the  closing  of  the  roentgen-ray  switch  as  well. 

Changes  in  the  filament  temperature  may  be  effected  by  means  of  a 
dial  switch  (see  Fig.  33),  which  controls  a  resistance  connected  in  series 
with  the  primary  of  the  filament  current  transformer.  Each  point  of 
the  dial,  with  the  same  tube,  always  means  the  same  temperature,  and 
hence  the  same  milliamperage.  The  higher  the  filament  current  the 
greater  the  milliamperage.  The  higher  the  voltage  backed  up  by  the 
tube  the  higher  the  penetration. 


THE  TRANSFORMER 


239 


THE  TRANSFORMER. 

The  rapid  development  of  modern  roentgenology  made  it  necessary 
to  increase  the  capacity  of  the  .r-ray  apparatus  in  order  to  meet  the 
requirements  of  therapeutic  irradiation  as  well  as  of  radiographic 
and  fluoroscopic  practice. 

These  demands  were  met  by  the  interrupterless  step-up  transformer. 
It  was  first  introduced  and  made  in  1907  by  H.  Clyde  Snook,  of 
Philadelphia  (see  Fig.  34.) 


Fig.  34. — A  modern  interrupterless  transformer. 


The  machine  consists  essentially  of  three  parts:  the  motor,  the  high- 
tension  transformer  and  the  high-tension  rectifier  or  commutator. 

The  interrupterless  transformer  makes  use  of  the  alternating  cur- 
rent, which  is  the  current  furnished  American  cities  by  most  of  the 
commercial  power  plants.  A  rotating  pole-changing  switch  rectifies 
the  high  potential  alternating  current  from  the  secondary  of  the  trans- 
former. To  secure  perfect  synchronism,  which  is  essential  for  recti- 
fication, the  motor  is  mounted  on  the  same  shaft  as  the  rectifier  and 
runs  about  1500  revolutions  per  minute.     The  motor  must  be  very 


240  DEEP  ROENTGENTHERAPY 

carefully  designed  and  constructed,  otherwise  it  will  cause  trouble  if 
there  is  any  possibility  of  its  running  not  absolutely  in  step  or  in 
synchronism  with  the  current.  The  transformer  is  capable  of  an 
enormous  output  and  easy  control;  there  is  no  inverse  current  and  no 
interrupter  is  needed. 

The  rectifying  switch  in  the  Snook  apparatus  is  of  the  cross-arm 
type  while  other  makes  usually  use  the  disk  t}^e. 

The  transformer  changes  voltage  approximately  in  the  ratio  of  the 
number  of  turns  in  the  primary  to  the  number  of  turns  in  the  secondary, 
and  changes  current  in  the  inverse  ratio.  Thus  a  particular  roentgen- 
ray  transformer  might  be  wound  with  500  turns  in  the  secondary  for 
each  turn  of  primary,  and  it  would  be  said  to  have  a  step-up  ratio  of 
500.  The  secondary  voltage  would  be  500  times  the  voltage  in  the 
primary  and  the  secondary  current  -J^^-  of  that  in  the  primary. 


Approximate  spark  gap, 

Primary  applied  voltage. 

Resultant  high  tension  voltage. 

inches. 

80 

40 

3 

90 

45 

31 

100 

50 

4 

110 

55 

4J 

120 

60 

5 

130 

65 

5J 

140 

70 

6 

150 

75 

61 

160 

80 

7 

170 

85 

7§ 

180 

90 

8 

190 

95 

8i 

200 

100 

9 

210 

105 

9^ 

220 

110 

10 

A  table  of  voltages  that  must  be  supplied  and  maintained  at  the 
primary  terminals  to  give  various  high-tension  voltages  can  easily  be 
made  in  this  case. 

Such  primary  voltages  can  be  secured  from  a  line  supply  of  220  volts 
by  proper  controllers,  either  the  rheostat  or  the  autotransformer 
control  (see  Fig.  35) .  The  former  is  an  adjustable  resistance  used  to 
consume  a  part  of  the  line  voltage  and  leave  the  proper  voltage  to  be 
applied  at  the  transformer. 

The  autotransformer  control  consists  of  a  continuous  coil  of  wire 
wound  around  an  iron  core  with  taps  taken  out  to  control  buttons  at 
proper  intervals.  If  an  alternating  current  be  applied  to  the  complete 
winding  of  such  a  coil  there  will  be  a  voltage  induced  in  any  part  of 
the  winding,  bearing  the  same  relation  to  the  applied  voltage  that 
the  number  of  turns  of  this  "part  of  the  winding  bears  to  the  number 
of  turns  in  the  whole  coil.  The  ratio  between  the  number  of  turns  in 
the  primary  and  secondary  circuits  is  changed  by  setting  the  control 
lever  on  the  various  buttons.  The  autotransformer  is  used  as  a  con- 
trol device  to  reduce  the  line  voltage  to  that  which  is  applied  to  the 
interrupt erless  transformer  primary.  Therefore  it  is  a  step^down 
transformer  and  has  fewer  turns  in  the  secondary  circuit  than  in  the 


THE  TRANSFORMER 


241 


primary.  As  the  control  handle  is  moved  to  higher  readings  more 
turns  are  cut  into  the  secondary  circuit  and  higher  voltage  is  applied 
to  the  primary  of  the  interrupterless  transformer. 

The  use  of  a  rheostat  to  control  tube  voltage  has  the  disadvantage 
that  slight  variations  in  tube  current  result  in  serious  changes  in  volt- 
age. The  voltage  "regulation"  under  various  loads  of  a  rheostat  con- 
trolled transformer  is  poor.  Softening  of  a  gas  tube  during  exposure  or 
fluctuation  in  the  filament  temperature  of  a  Coolidge  tube  will  lower 
the  voltage  10  kv.,  or  about  an  inch  of  spark  gap.  Hence  there  is  a  loss 
in  penetration.    Also,  if  there  were  a  break  in  the  Coolidge  filament  line 


Fig.  35. — The  control  table  with  autotransformer  and  rheostat  controls. 


or  polarity  were  wrong,  so  that  no  current  flowed  in  the  secondary 
circuit,  the  primary  voltage  would  rise  to  that  of  the  line,  with  con- 
siderable likelihood  of  sparking  to  the  patient  or  causing  damage  to 
the  apparatus. 

The  autotransformer  control  is  of  special  value  with  the  Coolidge 
tube,  as  in  this  tube  the  voltage  and  filament  current  are  independently 
controlled;  the  voltage  by  the  autotransformer  and  the  high-tension 
current  through  the  tube  by  adjustment  of  the  temperature  of  the 
cathode  filament.  If  the  filament  current  is  not  entirely  steady  with  a 
rheostat  control  the  radiation  would  be  reduced  in  quantity  and  be  less 
penetrating,  while  with  the  autotransformer  control  the  same  change 

VOL.  I 16 


242 


DEEP  ROENTGEN  THERAPY 


would  result  in  an  increase  in  quantity  and  also  in  penetration.  Hence 
the  cathode  filament  current  controller  and  the  autotransformer 
control  are  two  instruments  of  precision  which  give  us  almost  absolute 
control  of  penetration.  It  is  simple  and  accurate  and  can  be  duplicated 
day  after  day. 


Fig.  .36.— Tube  stand. 


It  is  important  to  note  that  in  using  the  autotransformer  control 
it  is  advisable  to  also  throw  in  the  rheostat  control.  If  anything  should 
go  wTong  with  the  former  the  latter  will  immediately  take  care  of  the 
changed  current  condition,  so  sparking  of  the  patient,  puncturing  the 
tube  or  other  accidents  are  effectually  prevented.  The  patient  also 
should  be  grounded.    A  wire  screen  netting  is  placed  over  the  patient, 


THE  TRANSFORMER 


243 


for  instance  the  lower  extremities.  It  is  weighted  down  by  suspending 
a  heavy  object  from  either  side.  The  wire  is  grounded  to  a  water  or 
waste  pipe.  Should  a  full  spark  strike  the  patient  it  is  thus  imme- 
diately dispersed  down  the  grounded  wire  and  the  patient  thus  remains 
protected. 

To  recapitulate:  ]Modern  deep  roentgentherapy  requires  for  the 
source  of  the  .r-ray  current  an  interrupterless  transformer,  an  auto- 
transformer  control,  a  Coolidge  tube  with  a  medium  focus  and  a 
transformer  control  for  the  cathode  filament  ciu-rent. 

Accessories. — A  great  variety  of  accessories  also  are  necessary  such 
as  a  tube  stand,  a  treatment  table,  markers  and  so  forth. 

A  very  simple  and  practical  tube  stand  is  showm  in  Fig.  36.  It  is 
arranged  so  that  the  tube  lies  parallel  to  the  axis  of  the  carrier,  though 


Fig.  37. — A  simple  but  practical  treatment  table. 

it  may  be  moved  in  any  direction.  The  former  position  is  necessary  in 
suprapubic  and  neck  treatments,  especially  when  crossfiring  must  be 
used.  It  is  advisable  to  ground  the  stand  to  a  water  pipe  to  prevent 
sparking  of  the  patient. 

The  treatment  table  should  be  a  wooden  one,  the  top  must  be  very 
carefully  padded,  so  the  patient  can  lie  on  it  for  any  length  of  time.  A 
common  examining  room  table,  as  reproduced  in  Fig.  37,  has  been 
found  very  practical  and  gives  great  satisfaction. 

The  patient  can  be  arranged  in  any  position  desired,  as  prone  position, 
lithotomy  position,  extended  neck  position  and  left  lateral. 

The  roentgen  treatment  room  should  be  large  and  well  ventilated. 
The  transformer  is  preferably  located  in  a  separate  room,  so  as  to  deaden 
its  noise  as  much  as  possible.  The  switchboards  are  located  in  a  small 
booth     The  partition  toward  the  patient  should  be  lined  with  lead- 


244  DEEP  ROENTGENTHERAPY 

sheeting  of  0.3  mm.  thickness.  A  window  of  leaded  glass  must  be  in- 
stalled, so  the  patient  may  be  continuously  observed  by  the  operators. 

The  patient  must  be  protected  by  leaded  rubber  sheeting.  An  opening 
3  inches  square  is  cut  in  about  the  center  which  exposes  the  part  of  the 
patient  to  be  treated.  To  obviate  any  error  in  applying  the  rays,  it  is 
necessary  to  map  out  the  area  to  be  treated  into  squares,  usually  of 
1^  inches.  This  is  best  done  by  using  a  skin  ink  composed  as  follows: 
I^ — ^Acidi  pyrogallici  1.0,  acetone  10.0,  liq.  ferri  perchlor.  "fort.  2.0, 
sp.  vini  menth.  ad  20.0;  m.  et  s.:  skin  ink.  The  areas  are  crossed  off 
with  the  same  ink  after  a  treatment,  so  errors  are  impossible.  A 
standard  to  mark  the  squares  should  be  used.  The  one  for  more  super- 
ficial work  should  have  16  squares  of  2  inches,  and  the  one  for  very  deep 
work  12  squares  of  1  j  inches  each.  The  smaller  squares  are  needed  to 
cut  out  the  greatly  dispersed  peripheral  rays  in  treating  deeply  located 
tumors.  This  precaution  must  be  observed  to  avoid  stimulation  of  the 
tissues  by  the  weak  peripheral  rays. 

The  compression  tube  must  be  built  so  that  it  tapers  down  to  a 
square  of  1|  inches  or  it  may  be  of  the  ordinary  cylinder  type.  Then  a 
lead  plate  ha\ing"the  same  diameter  as  the  tube  and  a  square  of  Ij 
inches  in  the  center  is  placed  on  a  given  square.  In  this  manner  no 
portion  of  the  body  surface  receives  any  rays  except  the  area  to  be 
treated  (see  Fig.  44) . 

We  also  must  employ  means  for  determining  the  erythem  dose  for 
each  Coolidge  tube  under  exactly  like  conditions  of  application.  This 
will  be  discussed  in  another  paragraph. 

Technic. — ^The  radiation  given  off  from  a  roentgen  tube,  i.  e.,  one 
backing  up  a  9-inch  spark  or  activated  by  100  kv.,  is  nearly  always  of  a 
heterogeneous  character.  It  not  only  emits  highly  penetrating  rays, 
but  simultaneously  a  varying  proportion  of  medium  hard  and  soft 
rays.  Half  of  the  medium  hard  rays  are  absorbed  within  the  upper 
2  cm.  of  tissue  beneath  the  skin,  while  one-half  of  the  soft  rays  do  not 
penetrate  deeper  than  abour  7  or  8  mm.  In  deep  roentgen-ray  therapy 
it  seems  to  be  desirable  to  only  use  rays  which  are  absorbed  at  the 
depth  of  the  diseased  organs  or  regions.  Rays  absorbed  without  this 
area  would  strike  healthy  tissue  which  is  not  desirable.  If  we  could 
filter  out  these  rays  we  would  gain  a  distinct  advantage.  This  can  be 
attained  by  the  interposition  of  a  filter,  usually  made  of  aluminum .  The 
questions  arise:  What  has  been  done  to  a  beam  of  .T-rays  on  inter- 
posing a  filter  in  its  path?  In  what  ways  have  its  intensity  and  char- 
acter been  altered?  The  quantitative  estimation  of  the  absorption 
suffered  by  a  beam  of  a--rays  in  its  passage  through  a  substance  may  be 
made  by  measuring  the  ionization  caused  by  the  beam  initially  and  to 
trace  the  gradual  diminution  in  this  ionization  as  successive  layers  of 
the  material  in  question  are  interposed  between  the  beam  and  the 
ionization  measure.  The  results  would  differ  according  to  whether  a' 
soft,  a  mediima  or  a  hard  tube  is  used. 

With  regard  to  the  penetration  of  animal  tissue  by  roentgen  rays  an 
extensive  series  of  measurements  were  made  in  1905  by  Perthes,  who 


THE  TRANSFORMER 


245 


found  that  the  absorption  by  most  of  the  tissues  was  extremely  near 
that  of  water.  He  also  determined  the  thickness  of  tissue  required  to 
reduce  the  intensity  of  roentgen  rays  by  a  certain  amount  as  measured 
by  a  fluorescent  screen  and  also  the  thickness  of  aluminum  which  pro- 
duced the  same  reduction.  From  the  values  given  in  his  monograph 
it  appears  that  aluminum  is  from  seven  to  ten  times  as  effective  an 
absorber  of  roentgen  rays  as  tissues  of  about  the  same  density  as  water. 
This  is  nearly  three  or  four  times  as  much  as  its  density  would  suggest. 
Guilleminot  has  made  an  elaborate  study  of  the  absorption  of  .T-rays 
by  determining  the  intensity  of  the  rays  after  passing  tlirough  various 
thicknesses  of  tissue;  this  was  done  for  screened  as  well  as  unscreened 
rays. 


Quality  of  rays. 


Surface.  10.5  cm.  1  cm.  2  cm.  3  em. 


4  cm.|5  cm.  6  om.|7cm. 


8  cm. 


4  Benoist 

5  Benoist 

6  Benoist 

7  Benoist 

8  Benoist 

8  Benoist  filter  1  mm.  Al. 
8  Benoist  2  mm.  Al. 
8  Benoist  3  mm.  Al. 
8  Benoist  4  mm.  Al. 
8  Benoist  5  mm.  Al. 


Dose  transmitted  100  65.0  43.0  22.0  13.0  8.0'  5.2  3.8'  2.6  1.8 
53.0  32.5  21.915.5  11.6  8.8  7.0  5.5 
63.0  44.0  33.0  26.0  21.0  17.2  14.4  12.0 
68.0  .50.0  39.0  32.0  26.5  22.8  19.7  17.2 
69.9  .52.7  42.0  34.8  29.5  25.5  22.3  19.6 
76.2  61.1  50.6  43.0  37.3  32.6  28.5  25.4 

80.4  67.0  57.1  49.4  43.3  38.2  33.8  30.1 

83.5  71.8  61.8  54.5  48.0  42.5  37.8  34.8 
86.0  74.5  65.4  57.8  51.3  45.7  41.0  37.0 
87.0  76.1  67.2  60.0  53.8  48.5  44.0  40.2 


100 

72.0 

100 

78.0 

100 

81.0 

100 

83.2 

100 

86.5 

100 

89.2 

100 

91.0 

100 

92.8 

100 

95.0 

A  variety  of  substances  may  be  used  when  it  is  desired  to  screen  a 
beam  of  roentgen  rays — that  is  to  say,  to  cut  off  its  softer  components. 
Salmond  has  made  a  comparison  of  the  efficacy  of  different  screens 
commonlv  used. 


Alumimum. 

Pure  paper. 

Tanned  leather. 

Cliamois  leather. 

Felt 

nun. 

mm. 

mm. 

mm. 

TTlTTl 

0.5 

3 

3 

10 

13 

1.0 

7 

7 

18 

30 

2.0 

13 

13 

35 

67 

3.0 

17 

16 

59 

97 

Porter  and  Christen  have  shown  that  in  order  to  apply  a  maximum 
intensity  of  rays  at  a  depth  d,  that  particular  radiation  should  be  chosen 
which  is  diminished  to  one-half  of  its  intensity  by  this  thickness  of 
tissue. 

Thus  the  interposition  of  a  proper  filter  arrests  all  the  rays  that 
would  otherwise  become  absorbed  in  the  skin  and  healthy  structures 
lying  in  the  path  of  the  rays  between  the  growth  to  be  treated  and  the 
source  of  the  rays.  However  the  er\"them  dose  of  filtered  rays  is  of  a 
different  intensity  than  that  of  unfiltered  rays.  If  a  pastille  placed 
above  the  filter  and  at  a  half  distance  from  the  focus  to  the  skin  surface 
shows  an  intensity  of  6  E.  within  ten  minutes  by  a  given  current,  the 
same  pastille  will  record  only  one  E.,  if  placed  on  the  skin  beneath  a 
filter  of  3  mm.  if  the  focal  distance  is  11  inches.  Therefore  the  time 
period  of  the  application  of  a  filtered  roentgen  ray  may  be  safely 
extended  without  any  corresponding  injury  to  the  skin. 

These  considerations  enable  us  to  select  that  particular  radiation 


246  DEEP  ROEXTGENTHERAPY 

necessary  in  the  treatment  of  deep-seated  lesions.  For  instance  let  us 
assume  we  were  treating  a  carcinoma  of  the  left  ovary.  Ihe  organ  lies 
on  an  average  8  cm.  beneath  the  skin  surface.    Hence  we  must  select 


Fig.  .38. — Wehnelt  radiometer 


a  ray  which  becomes  absorbed  by  one-half  at  a  depth  of  4  cm.  Refer- 
ring to  the  table  of  Guilleminot,  we  see  at  a  glance  that  a  tube  must  be 
used  of  a  hardness  of  8  Eenoist  and  an  aluminum  filter  of  3  mm. 
Again  we  intend  to  treat  a  breast  cancer  confined  entirely  to  the  organ. 


Pig.  39. — Heinz  Bauer  Qualimeter. 


The  radiation  is  applied  as  a  prophylactic  measure.  Anteriorly  the 
ray  should  penetrate  the  chest  wall,  which  is  about  4  cm.  Over  the 
sternimi  we  wish  to  penetrate  the  mediastinum,  which  is  10  cm.; 


THE  TRANSFORMER 


247 


posteriorly  we  propose  to  treat  the  Ijonphatic  structure,  including  the 
chest  wall,  which  measures  on  an  average  3  or  4  cm.  The  problem 
would  be  solved  as  follows:  Anterior  chest  wall  tube  7  Benoist,  2  mm. 
aluminum  filter;  sternum  tube  8  Benoist,  4  mm.  almninum  filter; 
laterally  and  posteriorly  tube  8  Benoist,  2  mm.  aluminum  filter. 

The  multiple  small  fields  and  cross-fire  method  described  has  a 
great  many  disadvantages:  the  penetration  of  the  rays  is  low,  and 
the  quality  heterogeneous.  The  higher  the  voltage  of  the  current  the 
shorter  the  wave  length  of  the  electrons  will  be  and  the  more  penetrat- 
ing or  harder  the  rays  must  be.  The  quantity  of  the  hard  rays  is  also 
much  larger  than  those  obtained  from  a  current  of  lower  voltage.  We 
are  conducting  experiments  with  a  coil  that  furnishes  current  up  to 
180,000  volts.  The  tube  is  charged  with  3  to  5  milliamperes.  The 
arms  of  the  tubes  as  at  present  built  must  be  lengthened  to  about 
20  inches  to  reduce  the  danger  of  puncturing.  Provision,  also,  must 
be  made  to  cool  the  tubes  either  by  water  or  oil.  The  focal  distance 
has  been  increased  to  24  inches.  The  metal  filters  consist  of  aluminum 
18  mm.  thick  or  pure  copper  1  mm.  thick.  The  compression  tube  has 
a  diameter  of  9  inches  at  the  base.  One  field  9  inches  in  diameter  over 
the  pubic  region  is  exposed  to  the  rays  for  one  consecutive  hour  and 
another  field  of  the  same  diameter  over  the  sacrum  and  buttocks  for 
thirty  to  forty-five  minutes.  The  difference  in  intensity  of  the  rays 
between  the  skin  surface  and  the  depth  is  very  small  and  almost 
negligible,  proving  the  homogeneous  quality  of  the  rays. 

The  next  question  to  decide  is:  How  do  we  determine  the  pene- 
trability of  the  radiation?  Various  methods  are  in  use :  The  radiom- 
eters of  Walter,  Benoist,  Wehnelt  and  Bauer.  I  have  used  the 
Wehnelt  and  Bauer  which  are  reproduced  in  Figs.  38  and  39. 

The  Wehnelt  radiometer  is  provided  with  a  wedge-shaped  aluminum 
strip,  and  along  this  a  flat  silver  strip,  both  of  which  can  be  moved  by 
means  of  a  ratchet  over  a  brass  plate  provided  with  a  thin  slit.  The 
apparatus  is  adjusted  until  both  strips  show  the  same  brightness  on  a 
fluorescent  screen.  A  scale  denotes  the  permeability  of  the  activated 
tube. 

The  Bauer  qualimeter  is  connected  by  a  wire  to  the  negative  terminal 
of  the  coil  or  cathode  of  the  tube.  It  is  a  static  electrometer  and  con- 
denser which  indicates  automatically  the  potential  of  the  cathode,  and 
hence  the  quality  of  the  radiation.  We  may  say  that  each  division 
represents  the  energy  of  ten  kilowatts.  Hence  if  the  Heinz  Bauer 
instrument  indicates  at  9,  we  assume  that  the  tube  is  charged  with 
90  to  100  kilovolts. 

The  comparative  value  of  the  instruments  most  frequently  used 
is  as  follows: 


Usual  termination. 

Very  soft. 

Soft. 

Medium. 

Hard. 

Very  hard. 

Bauer     .' 

1.0     2         3 

4 
6 

5         6           7 
7.5     9          10.5 
4-5     5-6       6-7 
5         6           7 

8 
12 
7-8 
8 

9         10 

Wehnelt 

1.5     3         4.5 

13.5     15 

Walter 

Benoist 

1          1-2     2-3 
12         3 

3-4 

4 

9         10 

248 


DEEP  ROENTGENTHERAPY 


The  method  of  estimation  of  dosage  depends  on  the  determination  of 
the  erythem  dose.  An  erythem  dose,  i.  e.,  one  E,  is  one  which  causes 
a  sHght  erythema  and  loss  of  hair  to  appear  on  the  skin  fourteen  days 
following  the  application.  It  is  apparent  that  the  application  to  a 
given  area  should  not  be  repeated  before  this  time-period  has  passed. 

The  estimation  of  an  erythem  dose  depends  on  the  change  the 
a;-rays  produce  on  a  disk  of  barium  platinum  cyanide,  the  green  color 
changing  to  a  brown.    By  experiment  the  exact  tint  was  found  which 


Holzknecht  quantimeter. 


the  pastilles  assumed  after  exposure  to  an  erythem  dose.  Holzknecht 
has  devised  a  color  scale.  The  pastille  is  compared  with  an  unexposed 
pastille  of  the, same  material  arranged  under  a  celluloid  film  of  red- 
brown  color,  increasing  gradually  in  intensity.  By  moving  the  exposed 
pastille  along  this  film,  the  discoloration  can  be  measured,  5H  equal 
10  x  or  an  erythem  dose.  Another  instrument  based  on  the  same 
principle  as  Holzknecht's  radiometer  and  frequently  employed  is  the 
quantimeter  of  Hampson,  shown  in  Fig.  41. 

The  methods  of  measuring  quality  and  quantity  of  rays  as  enumer- 
ated are  not  very  exacting  and  rather  liable  to  errors,  because  they  are 
dependent  on  color  determination.  This  is  liable  to  cause  subjective 
errors  on  account  of  individual  differences  in  judging  color  changes, 


THE  TRANSFORMER 


249 


varying  light  conditions  and  differences  arising  in  the  tint  of  the 
tablets  if  exposed  to  radiation,  and  sunlight. 

The  only  correct  and  scientific  method  must  be  based  on  the  ioniza- 
tion power  of  the  rays.  Such  instruments  are  known  as  ionization 
meters.  They  consist  of  an  electrometer  to  which  an  ionization 
chamber  is  attached.  The  apparatus  enables  one  to  determine  the 
exact  amount  of  electrostatic  units  emanating  from  an  activated 
roentgen  tube  within  a  known  time  period.  The  ionization  chamber  is 
constructed  so  it  may  be  inserted  into  the  vagina  or  the  rectum.  The 
exact  number  of  electrostatic  units  of  roentgen  rays  can  thus  be  deter- 
mined that  reach  the  posterior  pelvic  wall  in  the  treatment  of  pelvic 
carcinomata,  while  the  exact  surface  dosage  is  obtained  by  placing 
the  ionization  chamber  upon  the  exposed  skin  surface.    Kroenig  and 


Fig.  41. — Hampson's  quantimeter. 

Friedrich  have  gauged  the  skin  dose  as  170  e,  the  cancer  dose  as  150  e 
and  the  ovarian  dose  as  33  e.  The  skin  dose  causes  an  erythema  of  the 
first  degree.  The  carcinoma  dose  results  in  a  visible  and  palpable 
decrease  of  the  growth.  The  ovarian  dose  brings  about  amenorrhea, 
due  to  a  degeneration  of  the  ova  and  follicles  by  the  rays. 

The  quantity  of  roentgen  rays  received  by  a  given  object  depends 
on  (1)  the  quantity  of  x-rays  generated;  (2)  the  quality  of  the  tube 
radiation;  (3)  the  distance  between  the  focus  and  the  object;  (4) 
the  time  of  exposure;  (5)  the  sensitiveness  of  the  object. 

The  quantity  of  the  radiation  is  determined  by  the  filament  current, 
the  voltage  and  the  amperage,  which  also  give  us  the  quality.  Both  are 
subjected  to  the  determination  of  the  erythem  dosage,  which  gives  us 
the  time  duration.    The  latter  varies  according  to  the  distance  of  the 


250  DEEP  ROENTGENTHERAPY 

focus  from  the  skin.  Distance  has  a  great  influence,  because  the  inten- 
sity of  roentgen  rays  diminishes  inversely  as  the  square  of  the  distance 
increases.  If  the  focal  spot  is  40  cm.  from  the  skin  surface  it  requires 
four  times  as  many  minutes  to  obtain  an  erythem  dose  as  a  tube  ex- 
posed at  a  focal  distance  of  20  cm. 

The  Biological  Action  of  the  Rays. — A  study  of  the  biological  reaction 
of  tissues  to  radiation  enables  us  to  correctly  interpret  the  thera- 
peutic value  of  the  latter  and  assists  us  in  the  choice  of  the  quality 
and  quantity  of  rays  to  be  employed.  Since  the  effect  of  the  action 
of  rays,  whether  the  source  is  radium  or  a  roentgen  tube,  is  not  only 
local  but  also  general,  i.  e.,  systemic,  a  correct  interpretation  of  the 
systemic  reaction  to  the  rays  is  very  necessary.  The  latter  enables 
us  to  formulate  exact  indications  and  contra-indications  for  the 
remedial  use  of  radiations.  Not  only  that;  they  also  will  materially 
aid  us  in  the  prognosis  of  radiation  treatment. 

Some  of  the  earliest  observations  of  the  changes  occurring  in  malig- 
nant tumor  by  roentgen-ray  applications  were  reported  by  Clunet  in 
1910,  who  divided  the  changes  seen  in  squamous-cell  cancer  treated 
with  roentgen  rays  into  five  successive  phases:  (1)  The  latent  phase; 
(2)  development  of  giant  cells;  (3)  keratinization;  (4)  disintegration 
and  phagocytosis;  (5)  formation  of  connective  tissue.  The  latent 
phase  varies  from  six  to  fifteen  days.  During  this  time  no  changes  in 
the  cells  are  seen.  In  the  second  phase  we  see  the  formation  of  giant 
cells  characterized  by  an  enlargement  of  all  parts  of  the  cells,  which 
may  be  increased  in  diameter  as  much  as  two  or  three  times.  Atypical 
mitoses  are  increased  in  number.  The  nuclei  appear  much  enlarged 
and  chromophile.  During  the  third  phase  irregular  forms  of  a  pseudo- 
parasitic  character  appear  within  the  cells.  Keratinization  is  seen  in 
the  protoplasm  as  well  as  the  nuclei.  The  protoplasm  becomes  gran- 
ular, often  exhibiting  vacuolation.  The  granules  gradually  are  fused 
together  into  one  mass  of  keratin.  The  nucleus  may  show  karyor- 
rhexis,  diffusion  into  the"protoplasm  and  granulation.  At  this  time  also 
a  round-cell  infiltration  and  active  proliferation  of  fibroblasts  in  the 
stroma  become  very  marked.  Macrophages  and  microphages  appear, 
evidently  to  devour  the  degenerated  cells  and  cell  debris.  In  the  final 
phase  regeneration  is  completed  by  a  connective-tissue  formation.  All 
these  changes  are  identical  with  those  occurring  in  tissues  irradiated 
with  radium  rays  (see  Fig.  42). 

If,  after  some  time,  a  portion  of  the  scar  be  examined  microscopically, 
epithelial  cells  may  be  seen,  some  representing  giant  cells,  others 
degeneration  of  the  protoplasm  and  still  others  abnormal  stages  of 
nuclei.  They  are  probably  dormant  or  in  a  kind  of  lethargic  con- 
dition. If  the  treatment  is  not  continued  they  may  give  rise  to  recur- 
rences. 

Sarcoma  cells  exhibit  a  somewhat  similar  transition;  however,  the 
latent  phase  is  very  much  shorter,  being  only  one  or  two  days. 

The  changes  occurring  in  cells  by  roentgenization  are  identical  with 
those  seen  after  applications  of  radium  rays.    The  response  to  radiation 


THE  TRANSFORMER 


251 


by  the  cells  may  be  best  expressed  by  the  law  of  Bergonie  and  Tri- 
bondeau,  which  has  equal  importance  for  both  radiations:  "Immature 
cells,  and  cells  in  an  active  state  of  division  are  more  sensitive  to  rays 
than  are  cells  which  have  already  acquired  their  fixed  adult  morpholo- 
gical or  physiological  characters. "  Very  rapidly  growing  cells  are  the 
most  affected  of  any  by  radiations.  However,  different  rays  give  rise 
to  quite  different  effects  upon  one  and  the  same  cell.  They  have  a 
"differential"  action.  Thus  the  action  on  tissues  of  soft,  medium  and 
hard  roentgen  rays  differs  as  does  also  that  of  the  Alpha,  Beta  and 
Gamma  rays  of  radio-active  substances.    A  careful  distinction  should 


.tcvS?^-., 


^ 


Fig.  42. — Effect  of  roentgen  rays  on  cancer  tissue.  Mr.  M.,  Augustana  Hospital, 
No.  42283.  Carcinoma  of  neck  involving  muscles.  Tissue  removed  March  30,  1915. 
Low  power  magnification,  a,  carcinoma  cells;  b,  leukocytic  cells;  c,  connective-tissue 
fibrils;  d,  lymphocytic  infiltration. 


be  made  between  the  "differential"  action  which  different  rays  have 
upon  the  same  variety  of  cell,  and  the  "selective"  action  which  the 
same  kind  of  radiation  has  upon  the  many  different  varieties  of  cells. 
The  degree  of  selective  absorption  of  rays  by  living  cells  depends  on 
the  particular  phase  of  its  life  cycle,  their  species,  as  well  as  the  age  of 
the  host  whom  the  cells  inhabit.  Cell  elements  which  are  embryonal 
or  undifferentiated  are  destroyed  by  a  radiation  which  would  only 
cause  a  slight  reaction  in  the  surrounding  mature  or  highly  differen- 
tiated cells.  The  basal  cells  of  the  epidermis  and  hair  follicles,  lymphoid 
cells,  sex  cells,  as  ova  and  spermatozoa,  are  readily  killed  by  a  quantity 


252  DEEP  ROENTGENTHERAPY 

of  rays  which  would  leave  intact  the  surrounding  and  neighboring 
mature  cells. 

Selective  absorption  also  depends  on  the  elementary  variety  or 
species  of  the  cell,  whether  epithelial,  connective  tissue  or  endothelial, 
and  on  the  different  varieties  within  each  species.  Normal  connective- 
tissue  cells  are  less  receptive  than  normal  epithelial  cells.  Epithelial 
cells  of  the  basal  layer  of  the  skin  are  less  sensitive  than  those  of  the 
papillae  of  the  hair  follicles.  They  are  different  kinds  of  the  same 
species.  Lastly  the  tissues  of  a  child  are  much  more  easily  altered  by 
radiation  than  corresponding  tissue  elements  in  the  adult. 

The  observations  made  on  normal  cells  apply  with  equal  force  to 
abnormal  cells  and  tissues,  neoplastic  as  well  as  inflammatory. 

Remarkable  examples  of  radiosensitive  tumors  are  ectodermal  and 
basal-celled  epitheliomata  derived  from  the  basal-celled  layers  of  the 
epidermis,  lymphadenomata  originating  from  embryonal  lymph  cells, 
sarcomata  derived  from  embryonal  connective-tissue  cells,  and  in 
which  the  connective-tissue  fibrillse,  cartilagenous  and  osseous  tissues, 
have  undergone  resorption,  fibromata  in  which  fibroblasts  are  present 
in  large  numbers  and  do  not  develop  into  highly  differentiated  adult 
cells  and  connective-tissue  fibers. 

On  the  other  hand,  squamous-celled  epitheliomata,  fibrosarcomata, 
chondrosarcomata,  osteosarcomata  and  fibromata  in  which  atrophic 
fibroblasts  and  abundant  fibrous  tissue  have  been  retained  are  very 
refractory  to  radiation. 

The  action  of  roentgen  rays  on  neoplastic  cells  is  of  an  impeding, 
destructive  and  evolutional  character.  The  radiation  arrests  the 
growth  of  the  tumors  before  it  destroys  them  or  renders  them  harmless 
by  an  evolutional  process  or  metaplasia.  Arrest  of  growth  results 
from  a  cessation  of  the  function  of  mytosis  or  genoceptor.  Destruction 
of  tumor  cells  is  either  a  direct  or  an  indirect  process.  In  the  direct 
form  the  tumor  cells  undergo  necrobiosis.  The  cytoplasm  and  nucleus 
disintegrate,  the  cells  are  absorbed  by  phagocytosis.  In  the  indirect 
destruction  a  metamorphosis  of  the  tumor  cells  precedes  absorption. 
This  consists  in  a  hypertrophy  of  the  cells,  enlargement  of  the  nucleus, 
nucleolus  and  even  centrosomes,  so  they  appear  like  pseudoparasites 
and  achromatism,  vacuolation  and  granulation  of  protoplasm. 

The  evolutional  influence  of  roentgen  rays  on  tumor  cells  is  evidenced 
by  a  retrogression  or  stimulation  of  the  embryonic  tumor  cells  so  they 
develop  to  maturity.  To  understand  this  process  we  must  have  a  clear 
conception  of  the  formation,  growth  and  function  of  a  cancer  cell. 
Tumor  formation  deprives  the  cells  of  their  normal  functions.  They 
become  "strangers"  to  themselves  and  to  the  mature  normal  cells 
from  whence  they  originate.  The  growth  of  tumor  cells  is  not  only  the 
result  of  a  proliferation  of  a  single  embryonal  cell  group  but  also 
depends  on  a  retrogression  or  metamorphosis  of  normal  mature  cells 
to  an  embryonal  phase  after  they  have  become  included  into  the  cancer 
tumor.  By  a  process  of  evolution  the  embryonic  abnormal  cell  is 
stimulated  to  grow  and  developed  into  a  mature,  highly  differentiated 
normal  cell,  thus  becoming  benign. 


THE  TRANSFORMER  253 

The  action  of  roentgen  rays  on  inflammatory  tissues  depends  upon 
two  phenomena:  (1)  The  destruction  by  the  rays  of,  the  anatomical 
elements,  modified  by  inflammation;  (2)  the  absorption  of  the  degener- 
ated tissue  by  phagocytes  and  its  replacement  by  scar  tissue. 

This  statement  would  presuppose  that  inflammatory  products  are 
more  readily  acted  upon  by  the  rays  than  normal  tissues.  This,  indeed, 
is  borne  out  by  clinical  observation.  However,  the  reaction  to  radia- 
tions of  inflammatory  tissues  differs,  depending  upon  the  underlying 
bacterial  cause.  Thus,  simple  inflammatory  glands  are  quickly  in- 
fluenced by  a  few  exposures — however,  suppurating  glands  are  not 
amenable  to  radiation  treatment.  Lymphadenomatous  glands  are 
less  quickly  acted  upon,  but  they  invariably  diminish  in  size  after  a 
thorough  exposure.  Tuberculous  glands  are  less  readily  affected.  It 
requires  a  large  number  of  exposures  to  induce  retrogressive  changes, 
but  ultimately  they  also  slowly  respond  to  radiation  treatment. 

The  employment  of  radiations  in  any  form  leads  to  a  constitutional 
reaction  which  varies  in  the  time  of  onset  according  to  dosage  and 
character  of  rays,  the  type  and  location  of  the  tumor  or  tissue  and  the 
systemic  condition  of  the  patient.  The  constitutional  reaction  results 
from  the  changes  occurring  in  the  blood  by  the  action  of  the  radiation 
and  from  the  degeneration  set  up  in  the  growth  by  the  rays  which  leads 
to  an  absorption  of  protein  ferments  into  the  circulation  of  the  patient. 

Some  patients  possess  a  marked  idiosyncrasy  in  the  sense  that  the 
same  dose  of  radiation  will  provoke  a  reaction,  the  degree  of  which 
varies  with  the  individual.  Dosage  is  a  complex  quantity  and  includes 
the  quantity  and  quality  of  radiation,  the  distance  of  the  focus  of  the 
tube  from  the  body  surface,  the  area  over  which  the  rays  are  spread, 
the  nature  of  the  rays  selected,  the  filter  used,  and  the  kind  of  tissue  to 
which  they  are  applied.  In  describing  and  comparing  results  obtained 
we  should  always  state  the  size  of  tube,  the  hardness,  the  milliamperage, 
the  focal  distance,  the  filter,  the  size  and  number  of  each  field  or  portals 
of  entrance  and  the  time  duration  of  the  treatment.  We  also  must 
give  an  exact  statement  of  the  type  and  size  of  growth,  its  extent  and 
the  formation  of  glandular  and  distant  metastases.  Finally,  all  general 
constitutional  signs  must  be  stated  as  pulse-rate,  temperature,  general 
nutrition  of  the  patient,  whether  the  disease  has  rendered  the  patient 
quite  ill  and  moribund,  a  correct  urinalysis  and  a  complete  examina- 
tion of  the  blood,  including  a  differential  white  count,  and  pulse  and 
blood-pressure.  These  observations  should  be  made  and  recorded 
before  treatment  is  begun.  They  should  be  repeated  at  daily  intervals 
until  such  a  time  that  they  have  returned  to  normal  or  that  their 
permanent  existence  is  unquestionable.  The  patient  must  again  be 
subjected  to  the  same  routine  examinations  at  each  subsequent  course. 
It  is  only  in  this  way  that  we  are  able  to  correctly  interpret  the  con- 
stitutional reaction  and  the  efficacy  of  the  treatment  as  regards  the 
local  diseased  conditions  and  the  general  state  of  health  of  the  patient. 
The  pulse-rate  gives  us  valuable  information  about  the  influence  of  the 
disease  on  the  general  condition  of  the  patient.    A  rapid  pulse  is  usually 


254  DEEP  ROENTGENTHERAPY 

associated  with  an  advanced  cachexia  or  compHcating  infection.  A" 
rise  in  temperature  indicates  either  a  compHcating  infection  or  exten- 
sive destruction,  necrosis  and  absorption  of  tumor  debris.  Abnormal 
constituents  in  the  urine  may  mean  organic  kidney  disease  or  secondary 
disturbances  in  the  kidney  set  up  by  the  influence  of  the  tumor  on  the 
general  constitution.  Increase  in  the  total  nitrogen  and  purin  base 
output  is  a  direct  result  of  radiation.  Low  percentage  of  hemoglobin, 
decrease  in  the  number  of  erythrocytes  and  leukocytosis,  with  an 
increase  of  neutrophiles,  may  indicate  a  secondary  anemia  due  to 
hemorrhage  or  cachexia,  an  active  infectious  process,  and  so  forth. 
If  all  of  these  signs  are  absent  the  general  condition  of  the  patient  must 
be  termed  good.  If  one  or  all  are  present  they  either  indicate  compli- 
cations of  the  underlying  disease  or  constitutional  reaction  from  the 
radiation  treatment.  It  is  clear  that  we  could  not  determine  the 
presence  of  the  latter  if  a  painstaking  examination  did  not  precede  each 
course  of  treatment. 

Attention  to  the  changes  occurring  in  the  blood  by  the  action  of 
radiation  w^as  first  directed  by  Senn  in  1903  in  cases  of  leukemia.  This 
observation  led  to  numerous  investigations,  the  outstanding  feature  of 
which  w^as  that  a  diminution  in  the  total  number  of  white  cells  results 
from  the  general  effect  of  prolonged  exposure  to  .r-rays.  The  lympho- 
cytes appear  to  be  the  most  sensitive  of  the  white  cells,  the  number  of 
which  gradually  decreases,  while  there  seems  to  be  an  initial  increase 
in  the  polymorphonuclear  leukocytes.  Chronic  exposure  of  roentgenol- 
ogists to  the  ray  almost  invariably  leads  to  a  decrease  in  the  number 
of  erythrocytes,  without  apparently  affecting  their  general  health. 
(Aubertin.) 

Stevens  in  an  extensive  study  on  the  blood  in  cancer  under  roentgen- 
therapy  derives  the  following  conclusions:  Roentgen  rays,  applied 
in  repeated  large  doses,  with  deep  penetration,  profoundly  affect  the 
erythrocytes  of  human  beings.  For  the  first  few  days  the  lymphocytes 
are  suppressed  or  destroyed  by  large  doses  of  roentgen  rays  in  the 
treatment  of  cancer.  In  favorable  cases  this  is  followed  by  a  reaction 
with  h-mphocytosis  between  the  third  to  the  seventh  days,  which  may 
continue  almost  uninterruptedly  till  the  fourteenth  day,  or  it  may  stop 
shortly  after  the  seventh  day  and  reappear  more  strongly  and  per- 
sistently on  or  about  the  fourteenth  day.  There  is  a  strong  resem- 
blance between  the  curves  of  these  lymphocytic  reactions  and  those 
which  constitute  the  opsonic  index.  The  treatment  should  probably 
not  be  repeated  until  the  reaction  is  over.  The  repetition  of  the  dose 
should  probably  by  governed  by  the  reactions  in  the  blood  as  well  as  in 
the  skin,  the  former  being  much  more  sensitive  than  the  latter.  In 
some  cases  of  cancer  the  roentgen  rays  tend  to  stimulate  a  general 
immunity  if  lymphocytosis  is  an  indication  of  immunity.  The  action 
of  roentgen  rays  in  cancer,  therefore,  would  appear  to  be  twofold: 
local  by  its  destruction  of  disease  cells  and  general  by  stimulating  lym- 
phocytosis, and,  consequentlv,  resistance. 

The  clinical  symptoms  of  the  systemic  reaction  resemble  an  acute 


TREATMENT  255 

intoxication.  They  include  extreme  prostration,  together  with  such 
gastro-intestinal  symptoms  as  vomiting,  diarrhea  and  anorexia,  an 
increase  in  the  pulse-rate  and  a  rise  in  temperature.  At  the  same  time 
there  is  observed  an  increase  in  the  excretion  of  uric  acid,  the  total 
nitrogen  and  purin  bases  in  the  urine  and  also  a  marked  increase  in  the 
non-protein  nitrogen  in  the  blood.  All  observers  agree  that  the 
intoxication  results  from  the  destruction  of  tissue  cells  by  the  ray, 
particularly  tumor  cells,  on  account  of  the  much  increased  selective 
absorption  the  latter  possess  in  comparison  to  normal  mature  cells. 
The  liberated  protein  ferments  are  absorbed  into  the  circulation, 
causing  a  temporary  hyperleukocytosis.  The  decrease  in  the  number 
of  lymphocytes  is  the  result  of  a  directly  destructive  process  of  the  rays. 
As  the  blood  circulates  through  the  area  under  treatment  the  highly 
selective  absorption  of  rays  by  the  lymphocytes  causes  their  destruc- 
tion. The  tissue  injury  may  be  so  great  and  tissue  catabolism  so 
increased  that  the  intoxication  may  become  so  severe  as  to  cause  death. 

The  nausea  and  vomiting  so  often  observed  in  patients  during  the 
time  of  treatment  result  from  the  effects  of  the  rays  on  the  vasomotor 
system  and  the  inhalation  of  gases,  especially  ozone,  liberated  by  the 
high-tension  currents  in  the  treatment  room.  They  are  transitory  and 
immediately  subside  after  the  treatment. 

It  is  clear  that  an  organism  not  weakened  by  the  tumor  disease  is 
much  more  able  to  resist  the  toxic  action  of  rays  and  much  more  capable 
to  respond  to  the  sudden  demand  on  the  organism  for  the  complete 
disintegration  and  excretion  of  a  large  amount  of  the  products  of  tissue 
breakdown.  It  is  also  a  fact  that  treatments  should  not  be  repeated 
until  the  organism  is  entirely  freed  from  the  intoxication. 

TREATMENT. 

Having  discussed  the  source  of  the  ray,  the  technic  of  the  thera- 
peutic application,  the  degenerative  changes  brought  about  in  normal 
and  abnormal  tissue  and  the  effect  of  the  radiation  on  the  constitution 
of  the  patient,  it  now  behooves  us  to  discuss  the  employment  of 
roentgen  rays  in  surgical  diseases.  The  latter  may  be  divided  into 
several  divisions: 

1.  Malignant  growths. 

2.  Benign  growths. 

3.  Inflammatory  diseases. 

4.  Blood  diseases. 

1.  Malignant  Growths. — Success  in  cancer  therapy  can  only  be 
attained  by  the  total  eradication  or  degeneration  of  all  cancer  cells  in 
the  host  attacked  by  the  disease.  Whether  the  means  employed  are 
surgical  or  radiological  does  not  matter.  The  danger  in  the  treatment 
of  cancer  with  surgery  consists  in  the  fact  that  we  frequently  cannot 
totally  remove  all  of  the  cancer  tumor  and  the  latter  now  begins  to 
grow  with  an  increased  rapidity  due  to  a  rapid  autotransplantation  of 
tumor  cells  caused  by  an  incomplete  procedure.    The  danger  in  the 


256  DEEP  ROENTGENTHERAPY 

treatment  of  cancer  with  radioactive  substances  consists  in  the  fact 
that  we  cannot  rapidly  destroy  all  the  pathologic  cells.  We  stimulate 
proliferation.  An  accelerated  proliferation  increases  the  danger  of  the 
formation  of  metastases. 

Complete  surgical  eradication  of  a  neoplasm  is  the  best  available 
means  to  prolong  the  life  of  the  patient.  But  to  be  effective  it  must  be 
early.  An  anatomical  cure  can  be  obtained  only  if  absolutely  -all 
cancer  cells  have  been  removed  from  the  body  of  the  bearer.  It  is  only 
rarely  that  such  an  ideal  result  is  obtained.  Otherwise  recurrence 
could  not  be  the  rule  as  statistics  and  clinical  observations  clearly 
prove.  Surgical  eradication  is  in  most  cases  defective:  (1)  Because  the 
whole  growth  is  not  removed  and  the  roots  or  seeds  are  left  behind; 
(2)  because  these  vestiges  develop  with  an  increased  rapidity  when  the 
primary  tumor  is  removed;  (3)  because  operation  favors  the  formation 
of  distant  embolism,  sources  of  incurable  metastases.  Surgery  removes 
but  cannot  modify  cancer  cells  or  render  them  harmless.  However, 
as  we  have  shown  above,  roentgen  rays  can  annihilate  that  power  of 
boundless  cellular  activity  which  constitutes  the  secret,  the  malignancy 
of  cancer.  It  is  necessary  to  concentrate  a  sufficient  quantity  of 
penetrating  rays  into  the  depth  of  the  body  to  kill  the  cancer  cells 
without  seriously  impairing  the  skin  and  the  overlying  and  surrounding 
normal  organs  and  tissues.  Deep  roentgentherapy  correctly  applied 
enables  one  to  do  so.  It  is  clear  that  results  and  statistics  in  cancer 
therapy  would  be  very  much  improved  by  a  combination  of  surgery 
and  radiation  treatment.  It  also  follows  that  results  of  surgical 
trauma  of  cancer  cells  would  be  rendered  negligible  if  the  cells  were 
rendered  harmless  before  the  patient  is  subjected  to  operation.  Indeed 
the  method  of  treatment  of  cancer  tumor  at  our  clinic  during  the  past 
three  years  has  been  carried  out  along  this  line.  Namely,  we  first 
irradiate  the  growth,  the  neighboring  regions  and  the  regional  lymph 
gland  groups,  next  we  operate  early  and  radically  remove  all  that  is 
visible  and  palpable,  and  lastly  we  again  irradiate  the  former  seat  of 
the  tumor,  the  neighboring  tissues  and  the  regional  lymph  gland  groups. 
Wherever  it  is  possible  we  combine  radium  with  roentgen  therapy 
either  inserting  the  radium  tubes  through  the  natural  channels  into 
the  organs  or  carrying  radium  needles  through  small  openings  in 
the  skin  into  the  invaded  tissues  and  tumor  by  specially  constructed 
trochars. 

Success  in  roentgen-ray  therapy  can  only  be  attained  by  adhering 
most  rigidly  and  minutely  to  a  systematic  technic.  This  includes  the 
correct  determination  of  the  degree  of  penetration  of  the  ray,  the 
amount  necessary  to  degenerate  the  cancer  cells  and  the  proper  dis- 
tribution of  the  fields  to  be  radiated.  Figs.  43  to  46  show  at  a  glance 
the  methods  to  be  followed. 

The  degree  of  penetration  is  determined  by  referring  to  the  table 
of  Guilleminot  given  on  page  245.  The  amount  of  roentgen  rays 
necessary  to  degenerate  a  cancer  in  the  depth  of  the  abdominal  cavity 
has  been  accurately  determined  by  Bumm  who  found  that  from  3  to  5  E 


TREATMENT 


257 


of  massive,  filtered  roentgen  rays  are  necessary  to  destroy  a  carcinoma 
within  2  cm.  from  the  body  surface.  However,  it  takes  from  30  to  50  E 
to  obtain  the  same  result  in  the  depth  of  the  pelvis,  which  is  about  10 
cm.  beneath  the  compression  cylinder  if  the  latter  is  pressed  down  onto 
the  abdominal  organs.  The  tube  must  always  be  directed  toward  the 
cervix,  so  that  the  application  of  3  E  through  each  one  of  the  fields 


Fig.  43. — Arrangement  of  fields  in  treating  cancer  of  the  oral  cavity,  throat  and  neck, 

1  to  7  and  16  to  20  in  Figs.  17  and  18  would  give  an  amount  of  twelve 
times  3  E,  i.  e.,  36  E  or  360 X.  Thus  by  "cross-firing"  the  desned 
result  would  be  attained.  Four  such  courses  are  repeated  every  two 
or  three  weeks  to  make  doubly  sure  that  the  disease  has  been  arrested. 
If  surgical  removal  is  advisable  it  is  instituted  soon  after  the  reaction 
following  the  first  course  subsides,  i.  e.,  within  two  or  three  days. 


Fig.  44. — ^Arrangement  of  fields  on  anterior  chest  wall  in  cancer  of  chest. 


The  method  of  treatment  just  described  and  the  schematic  drawings 
of  the  fields  of  entrance  of  the  various  regions  of  the  body  will  enable 
anyone  to  pursue  the  plan  of  treatment  instituted  in  our  clinic. 

The  local  result  of  successful  ray  treatment  is  arrest  and  gradual  dis- 
appearance of  the  growth,  the  healing  and  epithelialization  of  necrotic 
ulcers  and  cessation  of  discharge  and  bleeding  and  in  favorable  instances 

VOL.  I 17 


258 


DEEP  ROENTGENTHERAPY 


subsidence  of  pain.  Constitutional  sjTnptoms  improve  proportionately 
Thus  appetite,  sleep,  weight  and  strength  return;  pulse  and  tempera- 
tiue  become  normal,  so  that  subjectively  the  patient  appears  to  be 
normal. 


1 8 1 9 1 10 !  11 ; 

h--t--t--t--1 

I   4  I   5  !   6  !    7    I 
I..,.-)... -I , > — , — I 

"  1   I  2  !   3   ! 


Fig.  45.— Arrangement  of  fields  in  suprapubic  regions  in  cancer  of  the  pelvic  organs. 

How  long  should  the  radiation  be  continued?  If  an  improvement  in 
the  local  and  constitutional  condition  does  not  ensue  within  six  to 
eight  weeks  the  treatment  should  be  discontinued  as  useless.  On  the 
other  hand,  should  the  local  and  constitutional  signs  show  amelioration 
or  cessation  the  patient  must  be  instructed  to  return  every  four  weeks 


Fig.  46. — Fields  over  perineum  and  buttocks  in  cancer  of  pelvic  organs. 

knee-chest  position. 


Patient  in 


for  examination.  On  the  slightest  sign  of  a  recurrence,  either  locally  or 
symptomatically,  another  course  of  radiation  must  be  instituted.  If 
after  a  time  period  of  two  years  the  patient  has  remained  apparently 
well  after  most  painstaking  examinations  the  interval  between  reex- 
aminations may  be  extended  to  three  months.    The  patient  should  be 


TREATMENT  259 

instructed  to  return  sooner  if  any  disturbance  appears.  After  five 
years,  during  which  time  the  patient  has  remained  free  of  any  recur- 
rence, the  patient  can  be  discharged  as  well,  although  careful  reexami- 
nations made  every  six  months  should  be  insisted  upon  for  some  time. 

In  conclusion,  we  must  always  realize  that  success  in  cancer  treat- 
ment can  only  be  attained  by  the  total  eradication  or  degeneration  of 
all  cancer  cells  present  in  the  body  of  a  victim  of  the  disease.  This 
principle  must  be  observed  if  we  are  to  expect  results  whether  the  means 
chosen  are  siugical  or  radiological.  The  danger  in  the  treatment  of 
cancer  with  surgery  consists  in  the  fact  that  we  cannot  always  remove 
all  tumor  tissue.  The  vestiges  left  now  grow  with  an  increased  rapidity 
and  by  autotransplantation  cause  secondary  growths  in  different  parts 
of  the  body.  The  danger  in  the  treatment  of  cancer  with  radio-active 
substances  consists  in  the  fact  that  proliferation  is  enormously  stimu- 
lated if  we  cannot  rapidly  destroy  all  the  pathological  cells.  An 
accelerated  proliferation  increases  the  danger  of  the  formation  of 
metastases. 

Sarcoma.— The  treatment  of  sarcomata  with  the  roentgen  ray 
depends  chiefly  on  the  histological  structure  of  the  growth.  A  spindle- 
celled  sarcoma  is  very  refractory  to  the  action  of  any  ray  while  a  round- 
celled  growth  responds  very  readily.  "  It  melts  away  like  snow  in  the 
sun"  is  a  very  apt  comparison  for  the  reaction.  Sarcomata  containing 
a  large  amount  of  adult  connective  tissue,  cartilage,  osseous  tissue, 
muscle  or  nerve  structure,  do  not  react  nearly  as  readily  as  a  growth 
composed  chiefly  of  embryonic  structures. 

We  invariably  combine  roentgentherapy  with  the  administration  of 
Coley's  vaccine. 

The  principles  of  the  application  of  the  massive  and  intensive 
roentgen  ray  are  the  same  in  this  class  of  growths  as  those  observed 
for  carcinoma.  However  the  prognosis  is  difi^erent.  If  a  patient  suffer- 
ing with  a  malignant  connective-tissue  tumor  has  remained  well  for 
one  year,  he  may  be  considered  cured. 

2.  Benign  Growths. — The  object  of  radiation  treatment  in  benign 
growths  is  to  render  them  symptomless.  This  may  necessitate  either 
the  arrest  of  some  abnormal  function  caused  in  the  organ  invaded  by 
the  tumor  or  the  reduction  in  size  of  the  growth  if  the  latter  causes  an 
obstruction. 

Benign  growths  of  the  following  organs  have  been  successfully 
subjected  to  roentgen-ray  treatment :  Diseases  and  enlargements  of  the 
thjToid  gland  complicated  with  hyperthjToidism,  enlargement  of  the 
thymus,  h^'pertrophy  and  benign  tumors  of  the  prostatic  gland  in  the 
male  accompanied  with  residual  m-ine,  and  myomata  uteri  causing 
profuse  uterine  hemorrhages. 

The  region  above  the  thyroid  and  thymus  glands  is  divided  into  four 
squares  of  2  inch  each,  or  if  the  gland  is  very  large  six  such  fields  are 
marked  off.  To  each  field  3  E  of  filtered  rays  are  applied,  the  technic 
not  dift'ering  from  that  employed  in  cancer.  At  the  end  of  two  weeks 
a  comparison  in  the  triad  of  symptoms  and  the  circumference  of  the 


260  DEEP  ROENTGENTHERAPY 

neck  is  made  with  that  existing  at  the  beginning  of  the  treatment.  The 
usual  general  treatment  must  be  observed,  i.  e.,  rest,  diet  and  inter- 
nal medication.  Such  radiation  treatment  is  indicated  whenever  the 
patient  suffering  from  hyperthyroidism  is  a  poor  surgical  risk  or  refuses 
surgical  treatment.  Radiations  should  be  continued  until  the  patient 
is  rendered  symptomless.  The  treatment  of  enlarged  thymus  glands 
is  conducted  according  to  the  one  recommended  for  the  thyroid  gland. 

Enlargements  of  the  prostatic  gland,  that  cannot  safely  be  subjected 
to  surgical  enucleation,  are  treated  by  applying  the  roentgen  rays 
through  the  perineum  and  the  suprapubic  route,  the  same  method  as 
in  treating  cancer  of  the  uterus  in  the  female.  If  radium  is  available 
it  should  be  used  in  conjunction  with  the  roentgen  ray.  It  is  best  to 
insert  radium  needles  into  each  lobe  of  the  prostate.  If  relief  is  not 
immediate  it  is  deemed  advisable  to  perform  a  suprapubic  cystotomy 
under  local  anesthesia.  It  is  of  course  understood  that  surgery  must 
be  resorted  to  unless  urgent  contra-indications  forbid  it. 

The  success  of  roentgen-ray  treatment  of  myomata  uteri  depends 
on  an  arrest  of  ovulation.  The  following  indications  must  be  observed : 
The  tumor  must  not  cause  pressure  symptoms.  It  must  not  be  compli- 
cated by  another  pathological  condition  in  the  pelvis.  It  should  not  be 
larger  than  a  newborn  infant's  head.  It  must  not  be  located  in  the 
cervix  or  be  pedunculated  or  subserous  or  submucous.  The  patient 
should  be  thirty-five  years  or  older.  However,  if  the  patient  is  a  poor 
surgical  risk  she  should  be  subjected  to  radiation  treatment  even  in 
the  presence  of  one  or  all  of  these  conditions. 

The  rays  are  applied  to  seven  portals  of  entrance  in  the  suprapubic 
region  as  advised  for  treatment  of  carcinoma  uteri.  A  course  must  be 
given  soon  after  the  cessation  of  a  menstrual  period  and  should  be 
repeated  every  four  weeks  until  amenorrhea  is  permanent. 

At  times  menstruation  recurs.  If  it  is  normal  it  need  not  cause  alarm. 
If  the  bleeding  becomes  profuse  another  course  of  radiation  treatment  is 
given.  Such  recurrences  result  from  a  reestablishment  of  ovulation. 
The  younger  the  subject  is  the  more  probable  the  likelihood  that 
menstruation  reappears. 

Reduction  in  the  size  of  the  tumor  takes  place  with  the  progressive 
senile  atrophy  of  the  genital  organs.  Such  tumors  may  gradually  and 
completely  disappear.  Should  the  myoma  contain  a  marked  admixture 
of  highly  differentiated  connective  tissue  and  connective-tissue  fibers 
a  reduction  in  size  or  total  disappearance  of  the  growth  is  unlikely. 
A  symptomless  myoma  uteri  does  not  necessitate  treatment.  There- 
fore, persistence  of  the  growth  is  not  an  indication  for  any  further 
treatment. 

3.  Inflammatory  Diseases. — Inflammatory  hypertrophies  have  been 
successfully  treated  by  roentgen  rays.  It  is  not  necessary  to  describe 
the  technic.  The  fields  of  entrance  are  outlined  exactly  the  same  as 
employed  in  the  treatment  of  cancer.  Though  the  treatment  is 
individualized  for  each  patient  yet  the  fields  are  always  outlined  in  the 
same  manner.    Thus  neglect  or  inaccuracy  are  impossible. 


TREATMENT  261 

Inflammatory  diseases  thus  treated  are  chronic  infections  and 
hypertrophy  of  glands,  tuberculous  adenitis,  tuberculous  diseases  of 
the  breast,  the  skin,  the  peritoneum,  the  abdominal  and  pelvic  organs, 
fibrosis  uteri  accompanied  by  menorrhagia,  hemorrhagic  myopathies, 
pseudoleukemia,  although  the  latter  is  probably  a  lymphosarcoma  and 
so  forth. 

The  tuberculous  process  must  be  free  of  cheesy  degeneration.  Other- 
wise the  latter  should  be  aspirated  before  radiation  treatment  is  begun. 
Therapeutic  results  obtained  in  such  tuberculous  diseases  are  better 
than  those  of  surgery. 

Radiation  treatment  in  tuberculous  and  chronic  inflammatory  dis- 
ease is  repeated  every  two  or  three  weeks  until  a  subsidence  of  all 
local  signs  of  the  disease  is  attained.  Should  the  process  not  yield  to 
the  treatment  within  six  to  eight  weeks  further  treatment  is  inadvisable. 
Recurrences  are  again  subjected  to  another  course  or  courses  of 
roentgen-ray  treatment. 

The  contra-indications  of  roentgen  therapy  in  bleeding  uteri  are 
the  same  as  for  bleeding  myomata  uteri.  However,  it  is  imperative 
that  malignancy  must  be  ruled  out.  In  doubt  hysterectomy  is  the 
only  correct  procedure.  It  must,  however,  be  preceded  and  followed  by 
irradiation  treatment. 

The  event  of  amenorrhea  means  successful  treatment.  Recurrences 
of  profuse  menses  necessitate  additional  courses  of  roentgen-ray 
treatment,  though  success  is  certain  if  indications  are  strictly  adhered 
to.  Failure  in  arresting  hemorrhage  means  existence  of  complications 
which  escaped  our  examination  findings. 

Roentgen  treatment  of  Hodgkin's  disease  constitutes  the  best 
palliative  method  we  possess.  It  surpasses  in  efficacy  any  other  thera- 
peutic procedure.  The  treatment  to  be  successful  must  be  extended 
over  all  of  the  glandular  organs,  and  especially  the  mediastinum  and 
spleen.  Disappearance  of  the  enlarged  Ijmph  nodes  indicates  success 
of  therapy  and  the  treatments  should  then  be  interrupted.  Reappear- 
ance of  swellings  necessitates  further  treatment. 

We  also  must  mention  the  rather  frequent  occurrence  of  keloid 
formation  in  scar  tissue  which  is  very  troublesome  in  some  and  objec- 
tionable from  a  cosmetic  standpoint  in  others.  Radiation  pushed  to 
the  extent  of  causing  a  superficial  burn  wiU  be  followed  by  a  dis- 
appearance of  the  keloid. 

In  chronic  malaria  roentgen  rays  applied  to  the  enlarged  liver  and 
spleen  will  cause  a  diminution  in  size.  However,  the  improvement 
is  a  symptomatic  one  only  as  the  schizomycetes  remain  undisturbed. 

4.  Blood  Diseases. — Diseases  of  the  blood  offer  a  thankful  field  for 
roentgen-ray  therapy.  Results  obtained  are  equally  as  good  if  not 
better  than  those  following  the  usual  methods  of  treatment.  The 
diseases  to  be  considered  are  polycythemia,  lymphatic  and  spleno- 
myelogenic  leukemia.  The  rays  must  be  applied  in  either  instance 
over  all  the  long  bones  and  the  spleen. 

In  polycythemia  a  reduction  in  the  red  corpuscles  is  readily  attained. 


262  DEEP  ROENTGENTHERAPY 

Horwitz  and  Falconer  report  a  case  of  polycythemia  vera.  On  May  18, 
1915,  a  blood  examination  showed  a  hemoglobin  percentage  of  105, 
12,400,000  red  blood  corpuscles  and  9000  white  blood  corpuscles.  The 
spleen  could  be  palpated  about  a  hand-breadth  below  the  costal 
border;  the  edge  was  rounded,  smooth  and  slightly  tender.  October 
9,  1916,  benzene  was  administered,  about  5  gm.  per  day,  until  33  gm. 
had  been  taken.  Xo^'ember  10  another  course  of  benzene  therapy 
was  given  until  S.5  gm.  had  been  taken.  November  23  to  28,  three 
additional  grams  of  benzene  were  given.  The  drug  had  to  be  stopped 
permanently  on  account  of  nausea,  gastric  discomfort  and  headaches. 
During  the  period  of  September  to  January  seven  roentgen-ray 
exposures  over  the  spleen  were  made  of  about  30  ma.  minutes  each. 
January,  1917,  the  blood  picture  showed  a  complete  return  to  normal, 
the  red  count  being  5,200,000,  the  white  count  9200  and  hemoglobin 
percentage  98.  The  spleen  also  had  completely  receded.  When  last 
seen,  February,  1918,  the  patient  was  continuing  well. 

In  lymphatic  leukemia  the  glands  must  be  rayed  in  addition  to  the 
bone-marrow  and  spleen.  A  combined  treatment  of  radium  and 
roentgen  ray  in  leukemias  is  preferable.  The  radium  should  be  applied 
to  the  splenic  area  and  the  .r-rays  to  the  bone-marrow.  The  white 
blood  count  returns  to  normal  and  the  red  blood  corpuscles  increase 
rapidly  within  two  or  tliree  weeks;  the  spleen  is  often  reduced  to  an 
almost  normal  size.  At  the  slightest  recurrence  another  course  of 
treatment  must  be  given.  Since  it  appears  that  the  number  of  the  white 
blood  corpuscles  increases  with  a  simultaneous  enlargement  of  the 
spleen  we  advise  splenectomy  in  every  case  as  soon  as  the  white  blood 
count  returns  to  normal.  Splenectomy  apparently  retards  a  recurrence. 
However,  when  it  takes  place  radiation  must  be  again  resorted  to,  the 
former  splenic  area  being  also  irradiated.  It  is  interesting  to  note 
that  irradiation  of  the  spleen  area  in  splenectomized  patients  is  often 
followed  by  a  remission.  The  latter  is  probably  caused  by  the  selective 
action  the  leukocyte  and  myelocyte  have  to  the  rays. 


INJURIES  AND  DISEASES  OF  THE  SKULL 
AND  ITS  COVERINGS. 

By  CHARLES  E.  KAHLKE,  M.D. 
COVEEINGS  OF  THE  SKULL. 

ANATOMY. 

The  several  layers  of  the  soft  tissues  covering  the  vault  of  the  skull 
are  so  constructed  and  so  arranged  with  relation  to  each  other  as  to 
form  a  most  suitable  covering  for  the  skull.  The  first  three  layers, 
viz.,  the  skin,  the  subcutaneous  fibro-fatty  layer  and  the  occipitofrontalis 
muscle  with  its  aponeurosis  (galea),  are  so  intimately  bound  together 
that  they  form  a  pad  by  themselves  constituting  what  is  usually  spoken 
of  as  the  scalp.  The  latter  is  freely  movable  over  the  skull  and  its 
closely-fitting  adherent  pericranium  because  of  the  laxity  of  the  sub- 
aponeurotic connective  tissue.  This  latter  tissue  is  of  such  a  nature  as 
to  admit  of  the  easy  accumulation  of  fluids,  even  throughout  its  entire 
extent,  from  brow  to  occiput  and  from  ear  to  ear,  and  hence  is  often 
incorrectly  referred  to  as  a  space.  In  infancy  the  scalp  is  very  thin  and 
velvety  and  is  very  loosely  attached.  In  subsequent  years,  when  pos- 
sessed of  a  good  growth  of  hair,  it  forms  a  thick,  dense,  resistant  cover- 
ing. When  the  hair  falls  out,  or  in  advanced  age,  it  again  becomes  thin, 
but  less  movable. 

The  skin  of  the  scalp  is  exceedingly  thick  and,  under  normal  con- 
ditions, heavily  beset  with  hair  follicles  and  sebaceous  glands.  The 
subcutaneous  layer  of  fibro-fatty  tissue  is  very  much  like  the  corre- 
sponding layer  in  the  palm  of  the  hand,  and  its  connective  tissue  is  so 
firm  as  to  prevent  any  appreciable  increase  in  the  amount  of  fat  such  as 
occurs  in  the  body  in  obesity  or  locally  in  the  form  of  a  fatty  tumor. 
The  pericranium  is  not  firmly  adherent  to  the  bone  except  at  the  suture 
lines  and  foramina  for  vessels.  While  it  serves  as  a  protection  to  the 
bone,  it  has  but  slight  boneforming  power  in  adults,  as  is  very  evident 
after  the  destruction  of  the  cranial  bones  from  injury  or  disease. 

Blood  Supply.— The  blood  supply  of  the  scalp  is  very  rich  and  is 
peculiar  in  that  the  vessels  are  found  almost  entirely  in  the  stin  itself, 
thus  allowing  the  scalp  to  be  floated  upon  a  large  subaponeurotic 
accumulation  of  fluid,  or  even  torn  away  from  the  skull  as  a  large 
pedicled  flap,  without  losing  its  nourishment.  The  subaponeurotic 
area  contains  very  few  vessels.  The  chief  arteries  of  supply  are  the 
frontal,  the  supraorbital,  temporal,  posterior  auricular  and  occipital. 
In  a  general  way  the  large  veins  accompany  the  large  arteries.    An 

(263) 


264     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

important  point  in  the  arrangement  of  the  venous  system  of  the  scalp 
is  the  communication  of  the  superficial  veins  with  those  of  the  diploe 
and  the  intracranial  sinuses,  notably  along  the  sagittal  suture,  the 
inner  angle  of  the  eye,  the  mastoid  region  and  along  the  base  generally. 


CORRUGATOR 


ILATATOR    NARIS    ANTERIOR 

ATATOR   NARIS    POSTERIOR 

MPRESSOR    NARIUM     MINOR 

DEPRESSOR  ALAE  NASI, 


Fig.  47. — Muscles'of  the  head,  face  and  neck.     (Gray.) 


Lymphatics. — ^The  lymphatic  vessels  form  a  very  rich  plexus  over 
the  vault  and  drain  into  the  necklace  of  glands  around  the  base  of  the 


INJURIES  OF  THE  COVERING  OF  THE  SKULL  265 

head;  those  of  the  forehead  passing  partly  through  the  lymphatics  of 
the  face  into  the  submaxillary  glands,  and  partly  to  the  parotid  glands; 
those  from  the  temporal  and  anterior  parietal  regions  to  the  parotid 
glands;  and  those  from  the  posterior  parietal  and  occipital  regions  to 
the  mastoid  and  suboccipital  glands. 

Nerves. — Of  the  nerves  supplying  the  scalp,  those  of  special  interest 
to  the  surgeon  are  sensory,  with  the  exception  of  one  of  the  temporal 
subdivisions  of  the  facial  nerve  supplying  the  frontalis. 

INJURIES  OF  THE  COVERING  OF  THE  SKULL. 

Wounds,  open  or  closed,  involving  the  scalp,  demand  an  immediate 
anatomical  diagnosis,  as  complete  as  possible.  In  many  contusions 
we  must  consider  the  possibility  of  an  underlying  fracture  or  intra- 
cranial injury.  If  we  are  dealing  with  a  punctured  wound,  we  must 
determine  whether  the  subaponeurotic  area,  the  so-called  dangerous 
area  of  the  scalp,  has  been  entered,  or  whether  the  skull  has  been 
penetrated.  Though  many  of  these  wounds,  from  the  standpoint  of 
trauma,  are  insignificant,  yet,  from  their  nature  and  location,  they  call 
forth  many  questions  as  to  hemorrhage  or  infection  in  the  near  future, 
and  as  to  epilepsy,  insanity  and  various  mental  states  in  the  remote 
future.  The  fate  of  many  a  case  depends  upon  the  diagnosis  and  treat-- 
ment  instituted  by  the  physician  first  called  to  the  case. 

Contusions. — In  the  case  of  contusion  the  findings  will  depend 
largely  upon  the  force  and  direction  of  the  blow,  and  partly  upon  the 
size  and  character  of  the  contusing  surface.  Thus  a  direct  blow, 
striking  the  head  squarely,  may  produce  a  contusion  resulting  merely 
in  a  hematoma  of  the  subcutaneous  or  subaponeurotic  area,  or  it  may 
split  the  scalp  in  such  a  way  as  to  resemble  an  incised  wound.  If  the 
blow,  on  the  other  hand,  falls  obliquely,  it  may  loosen  the  aponeurosis 
from  the  pericranium  or  even  the  pericranium  from  the  bone,  resulting 
in  a  more  extensive  extravasation  of  blood;  it  may  even  tear  up  a  flap 
of  the  soft  parts. 

Hematoma. — ^We  recognize  as  a  subcutaneous  hematoma,  a  swelling 
of  the  scalp  which  has  appeared  directly  after  an  injury  to  these  parts, 
and  which  has  the  following  characteristics:  It  is  painful,  tender, 
tense  and  moves  with  the  scalp.  Discoloration  is  more  or  less  marked. 
Fluctuation  is  usually  not  present  unless  it  is  over  the  brow  where  the 
skin  is  more  easily  separated  from  the  aponeurosis. 

Deep  hematomata  have  the  same  history  of  trauma  and  prompt 
appearance  of  the  tumor,  but  with  these  differences:  The  swelling 
is  usually  more  gradual  in  onset  and  tends  to  increase  in  size;  is  more 
extensive,  and  consequently  flatter;  it  does  not  move  with  the  scalp 
and  usually  fluctuates;  even  pulsation  may  be  noticed  where  a  large 
vessel  has  been  ruptured,  or  if  there  is  a  coincident  skull  fracture  with 
gaping.  Discoloration  is  not  so  marked  right  after  the  injury,  but  may 
appear  later.  These  deep  hemorrhages  may  lie  under  the  galea  or 
beneath  the  pericranium.    In  the  latter  case  they  are  known  as  cephal- 


266     IX JURIES  AXD  DISEASES  OF  SKULL  AXD  ITS  COVERIXGS 

hematomata.  If  the  hemorrhage  is  under  the  galea  and  extensive,  its 
location  would  be  easily  recognized;  if  under  the  pericranium,  it  would 
be  limited  in  outline  by  the  attachment  of  the  pericranium  to  the  suture 


Fig.  48. — Large  hemotoma  under  the  galea. 

lines  of  the  bone;  but  a  hematoma  under  the  aponeurosis,  of  limited 
size,  and  situated  over  one  cranial  bone  might  be  difficult  to  recognize 
from  a  collection  under  the  pericranium.  Cephalhematoma  is  rare  in 
adults.    It  occurs  chiefly  in  infants  and  is  due  to  injury  during  labor, 


Fig.  49. — Bony  wall  of  subpericranial  hematoma. 

the  hemorrhage  coming  from  the  vessels  between  the  pericranium  and 
skull.  It  appears  usually  on  the  second  or  third  day  after  delivery  and 
tends  to  increase  in  size  for  a  time.    These  deep  hemorrhages  are  alike 


INJURIES  OF  THE  COVERING  OF  THE  SKULL  267 

in  that  they  usually  have  a  firm  ring  of  reactionary  edema  at  the  border 
of  the  hemorrhagic  infiltration  of  the  tissues.  This  ring  is  elevated  and 
so  hard  in  contrast  to  the  rather  soft  fluctuating  center  of  the  hema- 
toma, and  so  gradual  in  its  rise  from  the  surrounding  normal  tissues, 
that  it  feels  much  like  the  edge  of  a  depressed  skull  fracture  and  is 
occasionally  mistaken  for  such.  Firm  and  continuous  pressure  on  any 
point  of  the  ring  will  cause  the  ridge  to  disappear  at  the  point  of  pres- 
sure. In  case  of  reasonable  doubt  as  to  fracture  it  is  best  to  make  an 
incision  and  examine  the  skull. 

All  of  the  hematomata,  both  superficial  and  deep,  tend  to  disappear 
spontaneously  by  absorption.  Occasionally  a  large  vessel  may  require 
ligation.  Only  rarely  will  the  blood  remain  long  enough  under  the  peri- 
cranium to  become  encysted,  thus  constituting  a  blood  cyst. 


Fig.  50. — Suppurating  cephalhematoma  in  an  infant  of  five  weeks.    Incised.    Death 
in  four  days.     Children's  Hospital.      (Ashhurst.) 

Diagnosis. — The  diagnosis  in  case  of  a  blood  cyst  is  to  be  based  upon 
the  history  of  injury,  the  location  and  non-inflammatory  nature  of  the 
swelling,  the  fluctuation,  the  absence  of  pulsation  and  the  non-reduci- 
bility  of  the  tumor.  There  may  be  a  thin  bony  shell  rising  up  from  the 
borders  toward  the  dome,  representing  the  bone-forming  power  of  the 
pericranium.  The  exploring  needle  would  reveal  reddish  or  yellowish 
fluid.  It  would  be  differentiated  from  meningocele  spuria  or  hernia 
cerebri  by  its  non-reducibility  on  pressure,  its  failure  to  increase  in 
size  or  tension  with  increased  intracranial  tension,  and  by  the  absence 
of  pulsation.  Cephalocele  would  have  the  characteristics  of  meningo- 
cele spuria,  but  it  would  be  situated  in  the  median  line  and  would  be 
congenital. 

Treatment. — In  case  a  hematoma  does  not  disappear  spontaneously 
in  the  course  of  ten  days  or  two  weeks,  it  should  be  aspirated  with  a 
large  needle  or  incised.  The  cavity  should  be  emptied  by  gentle 
pressure  and  a  light  compression  bandage  applied.    Any  thin  bony  shell 


268    INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

should  be  broken  do-vsii.  Special  care  should  be  observed  to  avoid 
infection.  In  case  infection  should  occur  it  should  be  recognized  early 
and  free  drainage  established. 

Contusion  xcith  ojpen  wounds  should  be  carefully  cleansed  by  first 
packing  sterile  or  mildly  antiseptic  gauze  into  the  wound,  shaving  the 
surrounding  area  and  disinfecting  in  the  usual  way.  Dry  sha\'ing, 
followed  by  the  application  of  tincture  of  iodin,  is  the  usual  emergency 
preparation.  Benzine  may  be  used  instead  of  iodin,  or  one  part  of 
iodin  in  1000  parts  of  benzine  may  be  used,  especially  if  grease  is 
present  in  the  wound.  Benzine  is  inflammable,  and  is  furthermore  very 
irritating  to  the  skin  if  allowed  to  lake  or  collect  in  creases  or  pockets, 
hence  it  must  be  handled  with  great  care.  Then  the  wound  should  be 
cleansed  with  a  mild  antiseptic,  preferably  a  1  per  cent,  or  3^  per  cent, 
iodin  solution;  all  dirt  and  cinders  ground  into  the  tissues  should  be 
removed  with  scissors  and  forceps.  If  the  edges  of  the  flaps  are  badly 
contused  or  very  dirty  on  the  raw  edge  they  should  be  trimmed  off. 
The  skull  should  be  carefully  mspected.  If  no  fracture  is  present  the 
wound  should  be  closed,  lea\ing  plenty  of  room  for  free  drainage. 
The  galea,  if  cut  or  torn,  as  it  usually  is  in  a  flap  wound,  should  be 
included  in  the  suture.  Where  the  wound  is  large  it  is  preferable  to 
shave  the  entire  scalp.  This  is  the  best  course  to  follow,  too,  if  the  scalp 
is  very  dirty.  No  scalp  wound  should  be  explored  until  every  detail  of 
surgical  cleanliness  has  been  carried  out. 

Reasonably  clean  incised  wounds  are  to  be  cleansed  the  same  as  the 
above,  except  that  it  is  not  necessary,  in  the  smaller  wounds,  to  shave 
the  skin  over  such  a  wide  area,  not  at  all  in  some  cases.  The  wound  in 
many  cases  can  be  sutured  without  drainage.  If  the  aponeurosis  has 
been  divided,  as  is  evidenced  by  the  gapmg  of  the  wound,  drainage 
should  be  provided.  Stitches  through  the  galea  should  be  removed  in 
forty-eight  hours  (Cushmg) .  It  is  well  to  paint  the  suture  Imes  with 
3|  per  cent,  iodin  solution  before  apphing  the  dressing.  In  case  a 
moderate-sized  flap  is  entirely  cut  away  an  attempt  should  be  made  to 
suture  it  in  place.  I  recently  had  an  interesting  case  of  a  young  woman 
whose  head  had  been  forced  through  the  glass  wind-shield  of  an  auto- 
mobile. The  glass  shaved  a  thick  Thiersch  graft,  f  by  4  inches,  from 
her  forehead.  At  one  end  of  the  graft  was  the  long  hair  of  the  scalp,  at 
the  other  the  hair  of  the  eyebrow.  The  graft,  which  I  discovered  in  the 
matted  han  at  the  back  of  the  head,  was  cleansed  m  sterile  water  and 
replaced  on  the  wound  which  had  been  cleansed  with  a  weak  lysol 
solution.  A  light  dry  compression  dressing,  fixed  wdth  adhesive  plaster, 
resulted  in  a  perfect  healing,  without  loss  of  the  hair  on  the  graft.  The 
dressing  was  not  disturbed  for  ten  days. 

Punctured  Wounds. — Punctured  wounds,  if  deep,  should  be  laid 
open  freely  enough  for  disinfection,  hemostasis  and  drainage.  Pockets 
should  be  cared  for  by  a  counter  drain  if  necessary.  If  not  deep,  and  if 
the  wound  of  entrance  is  small  and  caused  by  a  reasonably  clean  object 
swab  the  wound  ^\ath  3|  per  cent,  iodin  solution  and  dress  without 
suture  or  drain. 


INJURIES  OF  THE  COVERING  OF  THE  SKULL  269 

Every  case  of  marked  contusion  should  be  carefully  watched  for 
intracranial  complications  and  every  scalp  wound  for  infection.  Deep 
stitches  should  be  removed  in  forty-eight  hours,  superficial  ones  in  five 
days  at  the  latest. 

The  prophylactic  administration  of  1500  units  of  antitetanic  serum 
may  be  called  for  on  the  same  grounds  as  in  other  soiled  wounds, 
especially  of  the  punctured  variety. 

Complications. — The  chief  complication,  barring  skull  and  intra- 
cranial injuries,  that  may  arise  is  infection.  If  this  is  circumscribed, 
whether  superficial  or  deep,  removal  of  a  sufBcient  number  of  stitches 
to  allow  very  free  drainage  from  the  bottom  of  the  wound,  followed  by 
the  local  application  of  tincture  of  iodin,  is  usually  sufficient.  Wet 
boric  acid  dressings  are  indicated  in  the  more  serious  cases. 


Fig.  51. — Lacerated  wound  of  the  scalp,  with  subaponeurotic  cellulitis;  the  result  of 
sealing  the  wound  with  a  cotton  and  collodion  dressing.  Forty-eight  hoiirs  after  injury 
the  cellular  infiltrate  had  gravitated  into  the  temporal  region  where  it  was  arrested  by 
the  attachment  of  the  temporal  fascia  to  the  zygoma.     Episcopal  Hospital.     (Ashhurst.) 

If  the  infection  takes  the  form  of  a  diffuse  cellulitis  under  the  aponeu- 
rosis we  will  have  the  constitutional  symptoms  of  sepsis  plus  a  diffuse 
swelling  and  edema  of  the  scalp.  In  a  case  of  this  kind  the  entire  head 
should  be  shaved,  the  stitches  removed,  the  wound  opened  and  counter- 
drains  placed  in  the  lowermost  portions  of  the  subaponeurotic  area 
around  the  head.  Wet  boric  acid  dressings  are  of  service  here.  All 
infected  wounds  must  heal  by  granulation,  but  skin  grafting  in  suitable 
cases  with  loss  of  tissue  will  hasten  the  recovery.  Extension  of  the 
infection  to  the  bones  and  intracranial  regions  will  be  considered  under 
their  proper  headings. 

When  any  scalp  wound  becomes  even  mildly  infected  the  possi- 
bilities of  the  spread  of  the  infection  to  the  skull  or  intracranial  struc- 
tures is  so  great  that  it  is  not  wise  to  offer  a  favorable  prognosis.  To 
emphasize  this  point  I  will  cite  the  following  case:    A  laborer  in  a 


270    INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

factory  was  hit  on  the  head  with  a  belt  which  had  shpped  off  its  wheel. 
There  resulted  a  small  wound  over  the  left  parietal  region  which  did 
not  open  the  subaponeurotic  space,  nor  were  there  apparently  any 
e\'idences  of  other  deeper  injuries.  A  fellow-laborer  washed  and  dressed 
the  wound  and  the  patient  continued  with  his  work.  When  he  con- 
sulted his  physician  a  week  later  because  of  headache,  there  was  found 
a  healthy  looking  granulating  wound,  though  the  patient  stated  that 
there  had  been  "some  matter"  in  the  wound  a  few  days  previously. 
He  grew  slowly  but  progressively  worse,  with  all  the  classical  signs  of 
increasing  intracranial  tension,  plus  right-sided  convulsions.  Oper- 
ation disclosed  an  intact  skull  and  dura,  but  a  superficial  brain  abscess. 


Fig.  52. — Lines  for  incisions  for  subaponeurotic  suppuration. 

Subpericranial  suppuration,  like  cephalhematoma,  is  limited,  at  least 
for  some  time,  by  the  boundaries  of  a  single  bone.  This  infection  may 
arise  secondarily  to  an  osteomyelitis  caused  by  an  air  sinus  infection, 
or  it  may  develop  la  a  hematoma  as  the  result  of  operative  interference 
or  through  hematogenous  infection.  The  diagnosis  is  to  be  based 
upon  the  history  of  sinus  disease,  such  as  mastoiditis,  with  the  subse- 
quent appearance  of  a  deep  fluctuating  swelling  located  over  the  bone 
involved.  Other  cases  may  give  the  history  of  cephalhematoma,  with 
or  without  operative  interference.  All  of  the  cases  are  progressive  and 
are  accompanied  by  the  constitutional  symptoms  of  sepsis.  The  treat- 
ment consists  of  free  drainage,  and  careful  watching  for  complications. 

Avulsion  of  the  Scalp. — The  entire  scalp  may  be  torn  completely 
from  the  head,  or  it  may  retain  attachment  by  more  or  less  of  a  pedicle. 
In  the  latter  case  the  scalp  should  be  sutured  in  its  proper  position,  with 


INJURIES  OF  THE  COVERING  OF  THE  SKULL  271 

provision  for  free  drainage.  Davis/  reviewing  the  literature  up  to  191 1 , 
reports  92  cases  of  complete  and  30  of  incomplete  scalping.  Of  the 
former  the  scalp  was  replaced  21  times,  but  that  of  Malherbe'^  is  the 
only  one  which  has  resulted  in  even  partial  success  and  even  this  is 
doubtful,  as  Lejars  in  Urgent  Surgery,  vol.  1,  1910,  p.  87,  speaking  of 
the  case  says:  "The  scalp  died,  but  turned  into  a  parchment-like 
covering  which  remained  adherent  to  the  cranium,  and  under  which 
healing  took  place  without  complications.  In  such  a  case  the  reappli- 
cation  is  practically  only  a  dressing  with  the  skin."  Both  clinical  arid 
experimental  evidence  shows  that  it  is  useless  to  replace  the  scalp  in 
toto  and  expect  it  to  heal,  but  strips  of  the  scalp  may  be  successfully 
applied  to  the  periosteum  along  the  wound  edges,  as  immediate,  whole- 
thickness  grafts. 

Perimoff^  cites  a  successful  case  of  free  transplant  of  a  flap  of  hairy 
scalp  from  the  head  of  a  Tartar  to  the  head  of  a  Russian  officer,  who  had 
a  disfiguring  scar  on  the  temporal  region.  The  transplant  not  only 
lived,  but  the  hair  did  not  fall  out  afterward.  He  attributed  Lauen- 
stein's  failure  in  a  similar  case  to  the  use  of  iodobenzine.  Perimoff  used 
only  soap  and  water  as  cleansing  agents. 

In  complete  avulsion  early  skin  grafting  by  the  Thiersch  method 
should  be  performed.  Gushing  believes  that  extensive  wounds  healing 
by  granulation  may  lead  to  delicate  scars  and  possibly  epithelioma. 

Charles  H.  Mayo*  describes  a  practical  method  of  "hastening  the 
healing  of  denuded  surfaces  of  bone."  He  drills  holes  about  one  fourth 
inch  apart  through  the  outer  table  of  the  skull  into  the  vascular  diploe. 
"Through  these  perforations  granulations  are  rapidly  thrown  out  and 
soon  merge  together  on  the  surface,  allowing  an  abundant  blood  supply 
for  the  skin  grafts." 

Grafts  of  skin  from  the  patient  give  better  results  than  those  taken 
from  other  individuals.  In  the  latter  case  they  tend  to  disappear,  even 
though  they  may  "take"  in  the  early  stages. 

Gunshot  Wounds. — As  gunshot  wounds  of  the  scalp  are  usually 
only  minor  features  of  serious  head  injuries  the  treatment  is  usually 
given  under  the  head  of  skull  injuries.  In  case  a  spent  ball  becomes 
lodged  under  the  scalp  without  injury  to  the  bone  it  is  good  surgery  to 
remove  it,  as  this  can  be  safely  done,  and  thus  avoid  any  irritation  and 
secondary  infection.  Small  shot,  from  a  shotgun,  need  not  be  removed 
if  they  have  entered  as  a  scattering  shot  from  a  distance.  These  shot 
wounds  are  to  be  regarded  as  clean  wounds.  Merely  painting  the 
wound  of  entrance  with  tincture  of  iodin  is  all  that  is  necessary. 

Gases  have  been  mentioned  in  the  literature  of  bullets  traversing  the 
subaponeurotic  area  nearly  half  way  around  the  head  without  entering 
the  skull.  I  once  saw  a  case  in  which  a  similar  thing  happened  about 
the  chest.  In  a  shot  wound  of  this  sort  the  absence  of  the  usual  brain 
symptoms  would  be  a  striking  feature,  and  in  all  probability  the  track 

1  Johns  Hopkins  Hosp.  Rep.,  1911,  x\ri,  257. 

2  Bull,  med.,  1898,  No.  97,  p.  1121.  3  Zentralbl.  f.  Chir.,  1913,  p.  1443. 
^Ann.  Surg.,  September,  1914,  p.  371. 


272    INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

of  the  bullet  would  manifest  itself  a  day  or  two  later  by  a  streak  of 
discoloration  and  tenderness.  A  skiagraph  would  show  no  bullet  hole 
in  the  skull. 

That  an  absence  of  brain  symptoms  does  not  always  exclude  pene- 
tration of  the  skull  is  evidenced  by  a  case  of  mine  in  which  a  22  caliber 
bullet  entered  through  the  eyebrow.  A  drop  of  blood  at  the  latter 
site  was  wiped  away  and  the  incident  forgotten,  as  neither  the  patient 
(a  boy  of  twelve)  nor  his  friends  knew  he  was  shot.  He  remained  in 
a  normal  condition  until  three  weeks  later  when  sjniptoms  of  a  severe 
meningo-encephalitis  suddenly  developed,  resulting  in  death  two  days 
later.    At  the  autopsy  the  bullet  was  found  in  the  right  lateral  ventricle. 

Powder  stains  on  those  portions  of  the  scalp  not  covered  by  hair  are 
usually  so  disfiguring  as  to  demand  treatment.  In  recent  cases  the 
little  grains  of  powder  may  be  picked  out  wdth  a  needle  or  sharp- 
pointed  knife,  or  they  may  be  treated  by  the  hydrogen-dioxide  method. 
Crile,^  Rhoads^  and  Clark^  report  satisfactory  and  rapid  results.  The 
site  of  the  stain  should  be  kept  moist,  preferably  by  wet  dressings  of 
the  hydrogen  dioxide,  unless  the  latter  is  too  irritating.  Crile  states 
that  after  a  white  zone  has  appeared  around  and  under  the  grains  the 
latter  can  be  easily  picked  out  with  a  pointed  instrument.  Clark 
applied  a  wet  dressing  of  one  part  of  glycerin  and  three  parts  of  hydro- 
gen peroxide,  if  not  too  irritating,  and  the  stains  disappeared. 

Stelwagon^  speaks  very  highly  of  the  method  of  removal  of  the  grains 
by  a  cutaneous  trephine  of  small  caliber,  as  originally  suggested  by 
Watson.^  The  small  punch  is  pressed  firmly,  but  not  too  deeply  over 
the  speck,  using  a  rotary  motion.  The  little  disk  of  skin  which  pro- 
trudes through  the  opening  is  snipped  off,  and  the  cavity  filled  with 
powdered  subsulphate  of  iron  or  with  a  paste  of  the  tincture  of  benzoin 
and  boric  acid,  or  with  the  compound  powder  of  boric  acid  or  ace- 
tanilid.  He  also  mentions  the  method  of  tattooing  in  glycerol  of  appoid 
or  caroid.  Brault  tattoos  the  stained  area  with  a  needle  and  solution  of 
30  parts  of  zinc  chloride  to  40  parts  of  water,  then  paints  this  area 
lightly  with  the  same  solution  after  tattooing.  This  method  may  pro- 
duce a  deep  eschar  if  not  skilfully  carried  out. 

IMany  authors  ad\ise  the  use  of  the  electrol>i:ic  needle.  If  the  grains 
are  thickly  set  the  superficial  layer  of  the  skin  may  be  shaved  off  and 
skin  grafts  applied. 

DISEASES  OF  THE  SOFT  COVERINGS  OF  THE  SKULL. 

Erysipelas. — Erysipelas,  though  it  occurs  oftenest  about  the  head, 
is  not  common  as  a  primary  scalp  infection.  When  it  involves  the  scalp 
by  migration  from  the  face  the  diagnosis  is  easy,  but  when  it  starts 
in  the  hairy  scalp  the  condition  may  be  unrecognized  until  it  reaches 

>  Cleveland  Med.  Gaz.,  1896-1897,  xii,  183.  =  Am.  Med.,  1901,  i,  16. 

'Ibid.,  1901,  p.  384. 

*  Treatise  on  Diseases  of  the  Skin,  7th  ed.,  Philadelphia,  1914. 

6  Med.  Rec,  1878,  xiv,  78. 


DISEASES  OF  THE  SOFT  COVERINGS  OF  THE  SKULL      273 

the  free  surface  outside  of  the  hair  line,  where  it  takes  on  all  the  local 
characteristics  of  the  disease.  This  is  because  of  the  fact  that  in  ery- 
sipelas of  the  hairy  scalp  there  is  no  marked  redness  or  elevation  of  the 
skin  and  hence  no  sharp  cut  line  of  demarcation.  There  is,  however, 
some  edema  and  tenderness  on  pressure  over  the  involved  area,  and 
enlargement  and  tenderness  of  the  nearest  lymphatic  glands.  Always 
however,  there  are  the  usual  constitutional  symptoms  which  accompany 
erysipelas,  viz.;  a  sudden  rise  of  temperature,  often  to  103°  to  104°, 
initiated  in  most  cases  by  a  chill.  Headache,  vomiting  and  a  rapid 
pulse  are  common.  The  scalp  cases  often  have  a  stormy  course  from 
the  beginning,  with  delirium  and  even  unconsciousness  as  prominent 
sjTnptoms.  The  disease  is  usually  of  the  nine-day  type.  These  cases 
sometimes  arise  after  the  drainage  of  deep  abscesses,  as  in  cases  of 
mastoiditis.  For  this  reason  some  have  advised  that  the  opening  of 
these  abscesses  be  made  with  a  cautery  for  the  sake  of  sealing  up  the 
lymphatics.  This  latter  treatment,  however,  does  not  seem  indicated, 
and  is  seldom  used. 

Prognosis.^ — The  prognosis  is  not  bad  if  the  patient  is  a  healthy  adult. 
Complications,  such  as  phlegmon  or  intracranial  infection,  are  rare 
except  in  infants  or  debilitated  people,  or  where  there  has  been  deep 
contusion  with  hematomata  or  fracture — or  in  cases  of  meddlesome 
treatment.    The  prognosis  is  bad  in  alcoholics. 

Treatment. — Nutritious  liquid  diet,  good  elimination  of  the  toxins 
through  the  use  of  laxatives  and  the  free  administration  of  water  by 
mouth  or  proctoclysis,  combined  mth  the  local  use  of  mildly  anti- 
septic cooling  lotions,  such  as  equal  parts  of  alcohol  and  saturated  boric 
acid  solutions,  are  all  that  have  as  yet  proved  of  value  in  the  line  of 
treatment.  While  the  mild  lotions  may  relieve  pain  they  sometimes 
cause  eczema  and  so  may  occasionally  do  harm.  Antiseptic  ointments 
may  be  necessary  to  relieve  intense  itching.  The  solution  of  equal 
parts  of  alcohol  and  saturated  aqueous  solution  of  boric  acid  is  used  as 
a  wet  dressing,  being  covered  with  gutta-percha  tissue.  If  the  face 
also  is  involved  the  dressings  are  cut  in  the  form  of  a  mask.  Sera  have 
thus  far  not  proved  efficient.  Scarification  and  circumscribing  incisions 
are  to  be  reckoned  as  meddlesome.  Clipping  of  the  hair  will  permit 
more  efficient  cleansing  of  the  scalp.  An  ice-cap  may  control  the 
delirium.  Abscesses  are  to  be  drained,  and  a  failing  heart  is  to  be 
stimulated. 

Carbuncle. — Local  suppuratirms,  such  as  pustules,  boils  or  carbuncles 
of  the  hairy  scalp  are  uncommon,  except  at  the  hair  line  in  the  occipital 
region.  The  carbuncle  usually  starts  on  the  back  of  the  neck  and  invades 
the  hairy  scalp  secondarily,  though  I  had  one  case  starting  in  the  hairy 
scalp  just  above  the  base  of  the  mastoid  process.  The  carbuncle  begins 
like  a  boil  on  the  surface  of  the  skin,  but  soon  spreads  into  the  deeper 
tissues,  usually  to  the  fascia  covering  the  muscles,  giving  rise  to  a  firm, 
brawny  induration  rising  up  somewhat  like  a  truncated  cone.  It  is 
painful  and  tender,  and  the  skin  soon  undergoes  the  characteristic 
color  changes  of  inflamm-ation  from  a  red  to  a  reddish  purple.    In  this 

VOL.  I 18 


274     INJURIES  AND  DISEASES  OF  SKULL  AXD  ITS  COVERINGS 

dense  mass  of  subcutaneous  necrosis  are  multiple  small  pockets  of 
pus  which  break  through  the  discolored  surface  at  numerous  points, 
gi\'ing  rise  to  the  so-called  pepper-box  openings.  In  spite  of  these  spon- 
taneous openings  the  process  tends  to  spread  progressively  and  in  some 
cases  may  become  as  large  as  a  small  dinner  plate.  The  temperature 
may  not  be  marked. 

Prognosis. — While  the  prognosis  is  good  in  healthy  young  adults,  it 
is  bad  in  the  aged,  the  debilitated,  and  in  those  suffering  from  diabetes, 
in  whom  it  is  so  common.  In  any  case  the  prognosis  is  distinctly'  more 
favorable  if  the  condition  is  recognized  early  and  the  focus  promptly 
excised.  Simple  incisions  are  not  very  satisfactory,  and  curettement 
is  dangerous,  because  it  may  disseminate  the  infection. 

Operation. — The  operation  which  is  probably  as  satisfactory  as  any 
other  is  one  in  which  two  skin  liaps  are  raised,  through  an  H-shaped 
incision.  After  the  excision  of  the  necrotic  mass  and  painting  the  deep 
wound  with  tincture  of  iodin  the  flaps  are  sutured,  but  free  drainage 
instituted.  The  operation  should  be  done  under  gas  and  oxygen 
anesthesia. 

S5npliilis  of  the  Scalp. — Syphilis  of  the  scalp  is  of  interest  to  the  surgeon 
in  its  tertiary  stage  only.  It  offers  little  difficulty  as  a  rule  in  diagnosis, 
especially  when  accompanied,  as  it  usually  is,  by  other  manifestations 
of  the  disease.  Even  if  a  gumma  exists  as  a  solitary  lesion  it  possesses 
characteristics  which  stamp  it  as  luetic.  On  the  scalp  the  favorite 
seat  is  the  forehead,  occasionally  the  parietal  region.  It  may  start  as 
small,  flat,  ^eddish-b^o^\•n  nodules  in  the  skin  or  as  a  subcutaneous 
node.  In  the  former  case  they  are  multiple,  are  usually  arranged  in 
groups  and  tend  to  ulcerate  in  the  center  while  they  proliferate  at  the 
periphery  of  the  group.  The  ulceration  is  in  turn  usually  followed  by 
healing.  The  solitary  subcutaneous  nodule  develops  as  a  slow  inflam- 
matory process  which  may  become  arrested  and  absorbed,  or  which 
may  break  down  and  ulcerate.  The  skin,  which  is  at  first  movable  over 
the  nodule,  later  becomes  fixed,  discolored,  and  breaks  do\Mi.  Their 
favorite  seat  is  on  the  brow,  back  of  the  neck,  back  or  shin. 

The  characteristics  of  the  syphilitic  ulceration  are  the  sharply 
punched-out  appearance  of  the  edges,  the  dirty  sloughing  grayish  base, 
and  the  tendency  to  heal  with  the  formation  of  radiating  scars.  Where 
there  are  multiple  coalescing  skin  lesions  the  general  shape  of  the  ulcer 
is  spoken  of  as  serpiginous.  In  the  latter  case  the  most  of  the  forehead 
and  parietal  regions  may  be  covered  with  these  irregular  ulcers  and 
scars.  ^Yhen  the  solitary  ulcer  heals  it  usually  leaves  a  round  depressed 
scar. 

Diagnosis.^ — The  diagnosis  in  most  cases  can  be  made  upon  the 
appearance  of  the  local  lesion.  However,  concomitant  lesions  in  other 
parts  of  the  body  and  the  presence  of  a  positive  "Wassermann  reaction, 
or  the  finding  of  the  spirochetes,  clinches  the  diagnosis.  The  history 
of  the  primary  and  secondary  manifestations,  when  it  can  be  obtained, 
also  has  much  weight.  The  spirochetes  are  only  occasionally  found  in 
tertiary  lesions.    They  seem  to  be  very  few  in  number  and  are  found  only 


DISEASES  OF  THE  SOFT  COVERINGS  OF  THE  SKULL     275   . 


Fig.  53. — SyphUis  of  the  scalp.     (Hertzler.) 


Fig.  54. — Syphilis.     Nodular  gummatous  type.     (Knowles.) 


276    JXJURTES  AND  DISEASES  OF  SKULL  AXD  ITS  COVERINGS 

after  diligent  search.  That  they  are  sometimes  present  in  even  late 
tertiaries  is  evidenced  by  the  occasional,  but  unquestioned,  infectivity 
of  these  lesions  in  man  and,  experimentally,  in  monkeys. 

In  the  differential  diagnosis  we  must  exclude  lupus,  sarcoma  and 
carcinoma.  Liqms  occurs  most  frequently  upon  the  face,  near  the  nose, 
rarely  upon  the  forehead.  It  is  of  slower  growth,  has  not  the  serpig- 
inous outlines,  and  has  the  pale  flabby  granulations  so  characteristic 
of  tubercidosis.  The  edges  of  the  ulcer  are  irregular,  flat  and  under- 
mined. In  the  vast  majority  of  cases  the  nearest  lymph  glands  are 
involved,  as  are  also  other  tissues  and  organs  in  the  body.  INIost  cases 
will  give  a  positive  tuberculin  reaction.     Sarcoma,  like  gumma,  may 


Fig.  55. — Destruction  from  sypliilitic  gumma.     (Knowles.) 

spring  as  a  solitary  nodule  from  the  pericranium  or  subcutaneous  tissue. 
Like  gumma  it  may  be  bluish-red  and  softened  in  the  center  as  it  reaches 
the  skin,  but  it  does  not  present  the  bogginess  so  often  seen  in  gumma, 
as  for  some  time  it  is  more  or  less  encapsulated,  due  to  its  growing  by 
expansion  into  the  surrounding  tissues  rather  than  as  an  inflammatory 
infiltration.  When  a  sarcoma  leads  to  necrosis  of  the  skin  the  resulting 
ulcer  presents  more  of  a  hemorrhagic  or  yellow  gelatinous  degeneration, 
whereas  a  gumma,  on  opening,  reveals  a  sticky,  gummy,  cheese-like  mass 
in  the  center.  Sarcoma  is  of  more  rapid  growth  than  gumma.  Further- 
more, those  not  of  bony  origin  usually  arise  in  the  skin  rather  than  in 
the  subcutaneous  structures  and  belong  to  the  class  known  as  melano- 
sarcoma.    This  is  the  most  frequent  variety  found  m  the  skin,  and  it 


DISEASES  OF  THE  SOFT  COVERINGS  OF  THE  SKULL        277 

starts  as  a  rule  from  a  pigmented  mole  or  nevus.  It  is  exceedingly 
malignant  and  grows  rapidly.  Carcinoma  may  appear  as  a  deep  growth 
but  is  then  secondary.  The  superficial  epithelioma  is  ordinarily  easily 
recognized  by  its  irregular,  indurated,  elevated  margins  and  a  base 
which  bleeds  on  the  slightest  irritation.  It  almost  always  has  its 
starting  point  in  a  wart,  an  old  scar,  or  in  the  edge  of  an  old  unhealed 
lupus.  The  glands  are  involved  late.  It  is  seen  mostly  on  the  brow  or 
temporal  region  below  the  hair  line. 

Non-neoplastic  Swellings. — Swellings  containing  air  may  occur  as 
solitary  air  chambers  beneath  the  pericranium  or  as  an  emphysema. 
The  former  condition  is  known  as  pneumatocele  capitis  and  arises  from 
an  open  communication  between  the  subpericranial  area  and  the  out- 
side air  through  some  air-containing  cavity  like  a  sinus  (frontal  or 
mastoid) .  It  may  be  bilateral  in  the  frontal  and  occipital  regions.  The 
communication  may  be  congenital,  or  it  may  be  acquired  through 
injury  (fracture),  or  disease  resulting  in  erosion  of  the  bone. 


Fig.  56. — Pneumatocele  of  cranium. 

Diagnosis.^The  diagnosis  is  to  be  based  upon  the  presence  of  a 
swelling  overlying  the  bone  containing  the  sinus  involved,  the  swel- 
ling presenting  the  following  characteristics:  It  is  non-inflammatory 
and  painless;  is  tympanitic  on  percussion;  reducible  on  pressure  and 
refills  promptly  on  forced  expiratory  efforts,  sneezing,  coughing,  etc. 
In  addition  there  is  usually  the  history  of  injury  or  disease  involving 
the  sinus.  The  bone  itself  may  feel  rough  at  the  periphery  of  the 
swelling,  owing  to  the  mild  bone-forming  powers  of  the  pericranium. 

Emphysema  presents  itself  as  a  more  or  less  diffuse  flat  swelling  which 
occurs  right  after  a  fracture  involving  one  of  the  air-containing  sinuses. 
It  may  involve  the  subaponeurotic  or  subcutaneous  area  and  sometimes 
increases  in  area  on  forced  expiratory  efforts.  Pressure  on  the  swelling 
elicits  a  characteristic  dry  crackling  under  the  skin. 

In  the  differential  diagnosis  of  pneumatocele  it  may  be  said  that  the 
location  and  time  of  appearance  would  exclude  meningocele,  the  latter 


278    INJURIES  AND  DISEASES  OF  SKULL  AND  ITS   COVERINGS 

being  congenital  and  mesially  located.  As  the  air  sinuses  do  not  develop 
until  puberty,  pneumatocele  would  be  rare  before  that  time.  Because 
of  the  not  infrequent  occurrence  of  tuberculosis  of  the  mastoid  it  may  be 
necessary  to  exclude  cold  abscess  vmderneath  the  pericranium.  In  this 
case  the  swelling,  while  fluctuating,  would  not  be  reducible  on  pressure 
and  would  be  dull  on  percussion.  The  abscess  tends  to  work  its  way 
to  the  surface.  The  history  of  the  disease  and  the  presence  of  enlarge- 
ment of  the  nearest  lymph  glands  would  also  point  to  cold  abscess. 
Cephalhematoma  (blood  under  the  pericranium)  is  most  frequently 
found  over  the  parietal  bone  the  second  day  after  birth,  but  may  occur 
at  any  age,  after  injury,  and  in  the  same  location  where  pneumatoceles 
occur.  The  swelling,  however,  is  not  reducible,  and  is  dull  on  percus- 
sion. Ecchymosis  will  probably  be  present  after  the  lapse  of  a  few  days. 
As  in  air  tumor,  there  is  apt  to  be  a  ridge  of  bone  at  the  periphery  if  it 
lasts  more  than  two  weeks.  The  exploring  needle  would  settle  the 
diagnosis. 

A  pericranial  sinus,  though  infrequent,  should  be  thought  of.  It 
consists  of  a  "blood  cyst"  of  traumatic  origin,  situated  between  the 
pericranium  and  the  bone.  The  reported  cases  have  been  found  over 
the  brow  or  on  top  of  the  head  near  the  median  line,  and  none  has  been 
larger  than  a  walnut.  As  they  contain  circulating  blood  and  communi- 
cate with  the  superior  longitudinal  sinus  it  is  evident  that  they  are 
reducible  on  pressure,  and  develop  tension  on  forced  expiratory  efforts 
or  when  in  a  dependent  position.  They  are  dull  on  percussion.  A  small 
exploring  needle  would  settle  the  diagnosis. 

Treatment. — The  treatment  of  pneumatocele  that  oft'ers  the  most 
certain  results  is  the  Konig-Miiller  osteoplastic  operation,  though  in  a 
number  of  cases  other  methods,  such  as  incision  and  packing,  with 
compression,  freshening  the  edges  of  the  fracture,  etc.,  have  been 
successful.  Puncture  with  the  needle,  or  simple  compression,  iodin 
injection,  etc.,  are  not  favorably  considered.  One  would  naturally 
suppose  that  in  the  case  of  the  mastoid  a  puncture  of  the  ear  drum,  or  a 
drainage  operation  in  case  of  the  frontal  sinus,  would  effect  a  cure  by 
preventing  air  tension.    Infection  calls  for  drainage. 

Emphysema  arising  from  an  air-containing  sinus  calls  for  no  treat- 
ment. 

The  treatment  of  the  pericranial  sinuses,  like  that  of  spurious 
meningoceles,  is  to  let  them  alone,  unless  the  underlying  cause  can  be 
relieved.  Harvey  Gushing  described  two  cases  in  connection  with 
brain  tumors  which  disappeared  after  decompression. 

Meningocele  Spuria  (Traumatica)  or  Cephalohydrocele  Traumatica. 
— This,  as  its  name  implies,  is  a  false  meningocele  of  traumatic  origin. 
It  is  found  only  in  children  and,  while  its  existence  implies  both  sub- 
cutaneous fracture  and  rupture  of  the  dura,  its  persistence  implies 
some  alteration  in  the  secretion  or  absorption  of  the  cerebrospinal 
fluid  which  leads  to  a  persistent  increased  intracranial  tension.  For 
this  latter  reason  the  skull  opening  does  not  close  and  we  have  what  is 
known  as  the  chronic  form.     The  acute  varieties  without  persistent 


DISEASES  OF  THE  SOFT  COVERINGS  OF  THE  SKULL        279 

increased  tension  may  close  spontaneously,  or  after   aspiration  and 
compression  dressing. 

Diagnosis. — The  diagnosis  is  to  be  based  upon  the  history  of  injury 
during  birth,  or  later  as  the  result  of  a  fall  or  other  accident,  followed 
immediately  by  the  appearance  of  a  circumscribed  fluctuating  tumor 
beneath  the  scalp.  This  tumor  pulsates  synchronously  with  respiration 
and  the  heart  beats,  and  possesses  a  tension  which  varies  with  the 
intracranial  tension,  i.  e.,  it  is  increased  when  the  patient  cries,  coughs 
or  sneezes,  or  when  the  head  is  in  a  dependent  position,  and  diminishes 
when  the  child  is  quiet  or  when  the  head  is  elevated.  Reduction  by 
pressure  may  lead  to  sjTnptoms  of  acute  brain  compression.  As  the 
condition  follows  fracture  the  tumor  is  not  usually  situated  in  the 
median  line,  as  is  true  of  meningocele.  The  use  of  the  exploring  needle 
may  be  necessary  to  settle  the  early  diagnosis. 


Fig.  57. — Meningocele  spuria  traumatica. 


Fig.  57  is  a  photograph  of  a  two  and  one-half  year  old  boy  who, 
eighteen  months  previously,  fell  out  of  an  upstairs  barn  door,  striking 
on  the  back  of  his  head.  There  was  no  e\'idence  of  serious  trouble  until 
several  days  later  when  the  meningocele  was  noticed.  Two  months 
after  the  accident  I  found  a  fluctuating  swelling  the  size  of  a  grape- 
fruit. It  had  all  the  characteristics  of  a  meningocele.  On  deep  pressure 
the  corners  of  the  bones  at  the  lambda  could  be  felt  curled  outward. 
The  child  was  otherwise  normal  and  had  no  signs  of  choked  disks. 

One  month  later  the  boy  fell  from  his  little  wagon,  striking  on 
the  tumor.  Violent  con\nlsions  followed  for  several  hours.  These 
gradually  subsided,  leaving  a  left-sided  paralysis  which  has  gradually 


280     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

disappeared  until  at  the  present  time  he  is  about  normal,  except  for 
the  presence  of  the  tumor. 

No  operation  was  performed. 

Treatment. — Though  various  operations  have  been  devised,  surgical 
treatment  is  useless,  for  it  is  a  fact  that  under  normal  conditions  the 
fracture  will  heal  spontaneously,  while  with  persistent  increased  tension 
an  opening  will  be  maintained  in  spite  of  operation.  Furthermore  the 
cerebrospinal  fluid  is  apt  to  find  its  way  through  the  scalp  wound.  To 
say  the  least,  operation  will  not  only  fail  in  most  cases,  but  a  distinct 
danger  of  leakage  and  infection  will  have  been  added. 

TUMORS  OF  THE  SCALP. 

Dermoid  Cysts. — Dermoid  cysts,  being  congenital,  are  first  noticeable 
at  birth  or  any  time  up  to  puberty,  and  are  found  at  special  points 
of  predilection  where  there  has  been  an  infolding  of  the  skin,  viz., 
at  the  outer  border  of  the  orbit,  or  deep  in  the  orbit,  in  the  region 
of  the  mastoid  and  squamous  portions  of  the  temporal  bone,  and  in  the 
median  line  of  the  skull,  especially  at  the  root  of  the  nose  and  the  region 
of  the  fontanelles.  They  are  deeply  situated  above  or  beneath  the  peri- 
cranium, often  resting  in  a  saucer-shaped  depression  in  the  bone,  or 
even  hanging  from  the  bone  with  a  connective-tissue  pedicle,  especially 
in  the  occipital  region.  They  may  even  rest  on  the  dura  and  thus 
pulsate  with  the  brain.  In  very  rare  cases  they  may  be  found  in  the 
bone  itself,  especially  in  the  mastoid.  Not  being  attached  to  the  skin, 
inflammation  is  rare. 

Differential  Diagnosis. — The  differential  diagnosis  is  usually  not 
difficult,  especially  if  the  dermoid  is  found  in  one  of  its  favorite  locations 
In  the  rare  cases  where  it  is  resting  on  the  dura  in  the  median  line  it 
may  be  mistaken  for  cephalocele,  which  occurs  usually  at  the  glabella, 
or  near  a  fontanelle.  In  the  latter  condition  the  variations  of  intra- 
cranial tension  produce  corresponding  variations  in  the  tension  of  the 
tumor.  Furthermore,  cephalocele  is  more  or  less  reducible.  The  very 
rare  cases  of  serous  cysts  found  deep  in  the  midline  are  probably  hrain 
cysts  isolated  from  the  intracranial  space  during  closure  of  the  sutures. 
Sebaceous  cyst  is  attached  to  the  skin,  is  entirely  above  the  galea,  occurs 
later  in  life,  and  is  seldom  found  in  any  of  the  favorite  seats  of  dermoid 
cysts. 

Treatment. — The  treatment  consists  in  early  excision,  care  being 
taken  to  avoid  injury  of  the  dura  in  the  cases  resting  on  the  latter. 

Sebaceous  Cysts. — Sebaceous  cysts  commonly  known  as  atheromat- 
ous cysts,  or  irens,  offer  no  difficulties  in  diagnosis.  They  are  oval 
tumors  situated  partly  in  the  skin  and  partly  in  the  subcutaneous 
tissues,  varying  in  size  from  a  pea  to  a  walnut.  Occasionally  they  may 
be  much  larger.  The  small  ones  are  hard,  the  larger  ones  soft.  As  the 
tumor  grows  the  overlying  skin  becomes  tense,  thinned  and  devoid  of 
hair.  The  skin  at  the  summit  is  adherent  and  dotted  with  comedones. 
They  occur  mostly  in  adult  life  and  are  rare  before  puberty.    They  are 


TUMORS  OF  THE  SCALP 


281 


often  multiple  in  advanced  life.  They  grow  slowly  and  are  painless 
tmless  inflamed.  In  very  rare  cases  they  have  produced  sufficient 
pressure  to  cause  atrophy  of  the  underlying  bone.  They  may  be 
pedunculated  in  the  occipital  region. 

Treatment. — The  treatment  is  excision  under  local  anesthesia,  the 
essential  feature  being  the  complete  removal  of  the  sac.  The  latter  may 
be  difficult  in  case  a  friable,  thin-walled  cyst  should  rupture  during 
the  operation,  especially  as  the  surrounding  tissues  are  very  vascular  and 
bleed  freely.  An  elliptical  incision  which  allows  the  adherent  skin  to 
be  removed  with  the  sac  facilitates  removal  without  rupture  of  the  sac. 


Fig.  58. — Wens. 


Many  years'  duration;  movable,  non-sensitive,  hard. 

(Martin.) 


Adenoma. — Adenoma  of  the  skin  is  a  very  rare  tumor.  It  may 
arise  from  a  sebaceous  or  sweat  gland  and  may  appear  in  the  form  of  a 
warty  growth  or  a  subcutaneous  tumor.  In  the  case  of  the  adenoma 
sebaceum  one  can  often  see  the  openings  of  the  sebaceous  glands. 
Some  of  the  glands  may  develop  into  sebaceous  cysts. 

Cutaneous  Warts  and  Horns. — Cutaneous  warts  and  horns  which 
occur  in  the  hairy  scalp  are  readily  recognized.  As  they  are  not  infre- 
quently the  starting-point  of  malignant  growths  the  treatment  should  be 
complete  removal,  the  incision  being  deep  enough  to  prevent  recurrence. 

Hard  Fibroma. — Hard  fibroma  is  a  very  rare  tumor  of  the  scalp. 
The  case  reported  by  Gushing  from  Halsted's  clinic  was  a  slow-growing 


282     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS   COVERINGS 

hard  tumor  attached  to  the  movable  scalp.  It  had  a  mushroom  shape 
and  was  covered  with  a  thin  epithelium  devoid  of  hair.  The  soft 
fibromata  found  on  the  scalp  are  part  of  a  generalized  fibromatosis 
(Fibroma  molluscum)  and  are  easily  recognized.  The  treatment  is 
excision,  chiefly  for  cosmetic  reasons. 

Keloids. — Keloids  are  quite  common  in  the  scalp  and  offer  no  diffi- 
culty in  diagnosis.  They  are  found  chiefly  in  the  negro  race.  Their 
starting-point  is  in  the  superficial  scar  of  a  wound  or  healed  infection, 
and  as  they  involve  only  the  reticular  layers  of  the  cutis,  they  are  mov- 
able with  the  skin.  Their  general  appearance  is  that  of  a  red,  shining, 
hypertrophied  scar,  covered  with  epidermis,  but  free  from  hair.  At 
times  they  take  on  the  form  of  nodular  new  growths  of  considerable 
size. 

Differential  Diagnosis. —  Uypertrophied  scars  rarely  attain  much  size, 
and  after  a  time  tend  to  disappear  spontaneously.  They  are  seen 
chiefly  in  those  with  a  personal  or  family  history  of  tuberculosis. 

Treatment. — As  keloids  usually  recur  after  removal,  operation  is  not 
indicated,  especially  while  the  growth  is  enlarging.  As  to  remedies, 
warranting  some  consideration  the  following  may  be  mentioned: 
Thyroid  extract,  usually  in  conjunction  with  .r-ray;  thiosinamin  or 
fibrolysin  injected  into  the  keloid.  Static  electricity  in  the  form  of 
sparks  is  also  well  spoken  of  by  some  observers.  The  a:-ray  is  probably 
the  best  form  of  treatment.  Ochsner  states  that  he  has  had  many 
keloids  disappear  and  remain  permanently  well  after  intensive  .r-ray 
treatment.  He  gives  a  vigorous  treatment  daily  for  six  days;  then 
repeats  this  procedure  in  one  month. 

Frank  E.  Simpson^  describes  the  efficiency  of  radium  rays  in  the  treat- 
ment of  keloids.  Some  experience  is  necessary  in  order  that  one  may 
estimate  the  amount  of  raying  necessary.  The  apparatus  and  technic 
employed  vary  somewhat  with  the  type  of  lesion.  "In  practice  the 
theoretic  use  of  purely  selective  doses,  which  may  cause  the  keloid  to 
disappear,  must  often  give  way  to  the  more  rapid  method  of  destructive 
doses.  The  general  principle  of  using  a  sufficient  dose  to  produce  a 
slight  but  not  an  excessive  reaction  is  the  one  I  usually  follow."  He 
states  that  "In  upward  of  a  dozen  keloids  of  various  types  which  I 
have  treated  with  radium,  the  results  have  been  superior  to  those 
obtained  by  other  methods." 

Lipoma. — Lipoma  is  rare  in  the  scalp  When  present  it  is  most 
frequently  found  on  the  forehead,  under  the  occipitofrontalis  muscle 
or  under  the  fascia  of  the  temporal  muscle.  Being  situated  deeply  it 
loses  the  characteristic  lobulation  of  the  subcutaneous  variety,  and 
there  is  of  course  no  dimpling  of  the  skin.  It  is  immobile  because  it  is 
usually  attached  to  the  pericranium.  It  is  slow-growing  and  sessile, 
though  the  pedunculated  variety  has  been  seen. 

Differential  Diagnosis. — The  favorite  locations  for  dermoids  are  seldom 
the  seat  of  lipoma.    Dermoid  is  noticeable  at  birth  or  up  to  puberty, 

1  Jour.  Am.  Med.  Assn.,  April  17,  191.5,  pp.  1300  and  1301. 


TUMORS  OF  THE  SCALP  283 

lipoma  usually  later.  Cold  abscess  gives  a  history  of  preceding  tuber- 
culosis of  a  bony  sinus  (frontal  or  mastoid),  and  tends  to  perforate 
the  skin.  The  course  is  not  so  chronic.  While  cephalocele  is  congenital 
and  occurs  in  the  median  line,  and  presents  all  the  characteristics 
mentioned  under  the  diagnosis  of  this  condition,  still  it  must  not  be 
forgotten  that  lipoma  sometimes  overlies  it. 

Diseases  of  the  Nerves  of  the  Scalp. —  Neurofibroma,  Elephantiasis 
Nervorum,  Plexiform  Neuroma,  von  Recklinghausen's  Disease.  —  This 
is  a  rare  disease  of  early  life,  involving  the  scalp  nerves,  and  character- 
ized by  a  fibrous  thickening  of  the  peri-  and  endoneural  connective 
tissue.  It  is  situated  entirely  within  the  movable  scalp  and  starts  by 
predilection  in  the  frontotemporal  region,  often  from  a  wart  or  mole, 
and  frequently  after  injury,  and  spreads  out  over  the  side  of  the  head. 
In  a  well-developed  case  the  side  of  the  patient's  head  looks  like  a  land- 
slide, dragging  the  ear  and  outer  angle  of  the  eye  with  it.  The  scalp 
may  sag  even  to  the  shoulder  as  a  pendulous  mass.  The  skin  presents 
the  usual  appearances  of  elephantiasis,  thick,  rough,  ridgy  and  some- 
times fissured  or  ulcerated.  There  is  no  pain  unless  the  case  is  compli- 
cated by  secondary  changes. 

Diagnosis,.- — The  only  condition  to  be  considered  at  all  in  differential 
diagnosis  is  multiple  fibrosarcomatosis  of  the  peripheral  nervous  system. 

Treatment. — Operation  is  performed  for  cosmetic  reasons  and  because 
of  the  possibility  of  the  development  of  sarcoma.  The  dangers  of  the 
operation  are  hemorrhage  and  infection,  for  evident  reasons.  Because 
it  is  a  superficial  affection  it  is  not  necessary  to  go  below  the  subcutan- 
eous tissue. 

The  hyperesthesias,  neuralgias  and  herpes  zoster  are  considered  in 
another  chapter. 

Bloodvessels.  —  Conditions  Due  to  Injury.  —  Blood  cyst  or  sinus 
pericranii  has  already  been  described  as  often  being  due  to  a  torn 
emissary  vein  near  the  median  line  of  the  skull.  It  contains  circulating 
blood  and  communicates  with  the  superior  longitudinal  sinus. 

Traumatic  Aneurysm. — Traumatic  aneurysm,  usually  of  the  tem- 
poral artery  because  of  its  exposed  situation,  is  easily  recognized  by  the 
classical  signs  of  such  condition.  Here  we  have  a  tumor  appearing 
suddenly  at  the  site  of  an  injury,  the  tumor  possessing  an  expansile 
pulsation,  a  thrill  and  a  bruit  synchronous  with  the  heart  beat.  Pressure 
over  the  vessel  on  the  proximal  side  of  the  tumor  stops  these  symptoms 
and  leads  to  a  diminution  in  the  size  and  tension  of  the  tumor.  Pres- 
sure on  the  distal  side  leads  to  increase  in  the  size  and  tension  of  the 
tumor. 

Treatment.- — The  treatment  is  proximal  and  distal  ligation  and  extir- 
pation. 

Arteriovenous  Aneurysm. — Arteriovenous  aneurysm  has  the  same 
history  as  traumatic  aneurysm.  The  pulsating  tumor  possesses  a  thrill 
and  bruit,  exaggerated  during  systole.  In  addition,  the  anstomosing 
venous  trunk  and  its  immediate  tributaries  are  markedly  dilated,  and 
pulsate  with  the  artery,  owing  to  a  reversal  of  their  stream. 


284     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

Aneurysmal  Varix. — Aneurysmal  varix  is  the  same  as  the  above 
except  tliat  there  is  no  sac  or  tumor.  It  is  sometimes  quite  difficult 
to  differentiate  clinically  the  arteries  from  the  veins,  and  occasionally 
it  may  be  difficult  to  differentiate  this  condition  from  a  racemose 
aneurysm. 

Fig.  59  is  a  photograph  of  a  case  of  aneurysmal  varix  due  to  a  shot 
wound  sustained  fifteen  years  previously.  The  patient,  in  getting  out  of 
a  boat,  drew  the  gun,  muzzle  first,  out  after  him,  with  the  result  that 
the  gun  was  discharged,  many  duck  shot  being  deeply  embedded  in 
the  side  of  his  face.  The  buzzing  tumor  w^as  noticed  immediately 
afterward.  Though  the  venous  enlargement  was  progressing  very 
slowly  an  operation  was  demanded  to  relieve  the  buzzing.  During 
the  operation  for  ligation  of  the  external  carotid  between  the  superior 


Fig.  59. — Ancurvsmal  varix. 


th^Toid  and  lingual  arteries  the  veins  in  the  neighborhood  were  found 
to  be  very  much  dilated.  The  facial  was  the  size  of  my  little  finger, 
while  the  temporal  was  half  again  as  large.  The  ligation  stopped  the 
buzzing  completely.  Excision  was  impossible  as  the  anastomosis 
evidently  occurred  in  the  external  carotid  near  its  bifurcation  in  the 
parotid  gland. 

Treatment. — The  treatment  for  these  cases  is  extirpation  or  exclusion, 
if  possible,  of  both  arterial  and  venous  trunks  near  the  sac  or  anas- 
tomosis. This  may  be  difficult  owing  to  the  distended  thickened  veins 
in  the  dense  tissues  of  the  scalp.  Gushing  advises  the  plan  which 
Krause  and  Korte  practice  in  cases  of  cirsoid  aneurysm,  viz.,  lifting  a 
skin  flap  through  a  crescentic  incision,  and  dissecting  the  vessels  from 
underneath.    The  incision  is  to  extend  down  to  the  galea. 


TUMORS  OF  THE  SCALP 


285 


Cirsoid  Aneurysm,  Aneurysm  by  Anastomosis,  Plexiform  Angioma, 
Rankenangiom,  Angioma  Arteriale  Racemosum.  —  Of  all  the  terms 
applied  to  this  rare  condition,  the  last  one  is  the  most  descriptive,  for 
it  is  really  more  of  an  arterial  angioma  than  an  aneurysm.  It  consists 
of  a  tumor-like  aggregation  of  dilated,  elongated  and  tortuous  arteries, 
involving  primarily  some  definite  "arterial  tree."  This  dilatation 
implicates  even  the  fine  capillaries  and  sometimes  also  the  veins.  It 
seems  to  progressively  invade  the  apparently  normal  vessels  at  the 
periphery  until  at  times  even  the  entire  scalp  and  face  may  be  involved. 
The  cause  of  this  condition  is  not  known,  but  the  starting  point  is  often 
a  simple  angioma  or  vascular  scar.  Trauma  is  sometimes  a  factor. 
It  usually  starts  in  the  region  of  the  temple  or  ear,  though  it  may  be 
found  in  any  portion  of  the  scalp  or  in  other  parts  of  the  body. 


Fig.  60. — Cirsoid  aneurysm  of  the  scalp.     (Hertzler.) 


The  tumor  is  rather  flat  and  presents  an  irregularly  undulating  sur- 
face, only  slightly  raised  above  the  surrounding  surface.  Through  the 
thin  overlying  skin  can  usually  be  seen  a  bluish  tint  and  the  pulsating 
vessels.  On  picking  up  the  skin  and  vessels  between  the  fingers  the 
plexus  of  pulsating  arteries  and  veins  feels  like  a  bunch  of  earth  worms. 
A  distinct  systolic  thrill  and  bruit  are  present  and  they  cannot  be 
obliterated  by  pressure.  Subjective  symptoms  of  noises  in  the  head, 
dizziness  and  faintness  are  common.  There  is  always  danger  of  fatal 
hemorrhage. 


286     INJURIES  AND  DISEASES  OF  SKULL   AND  ITS  COVERINGS 

Differential  Diagnosis. — Differential  diagnosis  may  possibly  call  for 
consideration  of  arteriovenous  aneurysm  or  aneurysmal  varix. 

Treatment. — The  treatment  consists  in  extirpation  if  possible.  This 
should  be  attempted,  if  the  risk  is  not  too  great,  because  of  the  danger 
of  hemorrhage  in  the  non-operated  cases.  When  one  stops  to  consider 
that  sometimes  the  vessel  changes  extend  through  deep  communicating 
vessels  to  the  subaponeurotic  area  or  even  to  the  intracranial  region, 
the  possible  difficulties  are  manifest.  The  most  successful  of  the  radical 
procedures  is  that  consisting  of  the  raising  of  a  flap  of  scalp  and  vessels 
with  dissection  of  the  vessels  from  the  undersurface  of  the  flap.  This 
is  facilitated  by  first  ligating  the  external  carotid  or,  in  suitable  cases, 
by  the  application  of  a  rubber  constrictor  about  the  head  just  above  the 
ears.  The  next  best  treatment  so  far  has  been  the  multiple  ligations 
at  the  borders  at  different  sittings.  Simple  ligations  of  the  main  affer- 
ent trunks  are  of  no  service,  while  injections,  cauterization,  etc.,  carry 
with  them  real  dangers  rather  than  benefits. 

Wyeth  reports  a  case  involving  one-half  of  the  scalp  cured  by  the 
injection  of  boiling  water.  Under  ether  he  injected  the  water  along  the 
course  of  the  chief  arteries  leading  to  the  tumor,  then  through  the  tumor 
from  side  to  side  in  various  directions  until  pulsation  ceased.  The  case 
remained  well.  The  following  is  quoted  from  Wyeth's  article:  "The 
needle  was  entered  along  the  course  of  the  arteries  leading  ijito  the 
tumor,  beginning  about  two  inches  from  the  mass,  a  quantity  of  boiling 
water  sufficient  to  coagulate  these  vessels  being  employed.  It  was  then 
introduced  through  the  tumor  from  side  to  side,  injecting  about  a  dram, 
withdrawing  the  needle  for  one-half  of  an  inch  and  then  repeating  this 
procedure  until  the  entire  mass  had  ceased  to  pulsate.  The  quantity  of 
boiling  water  so  used  was  between  five  and  six  ounces.  Temperature 
on  the  surface  was  noticed  by  touch,  and  when  the  heat  became  very 
perceptible  to  the  hand  and  the  skin  began  to  bleach,  the  injections  in 
that  particular  area  were  discontinued.  The  warty  growths  noticed  on 
the  surface  of  the  scalp  were  touched  with  the  Paquelin  cautery.  Xo 
reaction  followed  the  operation.  The  patient  complained  of  no  pain, 
but  there  was  a  very  considerable  edema  of  the  scalp,  and  this,  begin- 
ning on  the  left  (the  side  of  operation),  closed  the  left  eye  and  spread 
over  the  face,  closing  the  right  eye  within  forty-eight  hours.  The 
swelling  spread  as  far  down,  as  the  neck  and  was  so  great  that  had  I 
cause  to  repeat  a  similar  operation  I  would  use  only  about  one-half 
the  quantity  of  water,  and  would  then  repeat  the  operation  after  an 
interval  of  about  a  week." 

Neoplastic  Vessel  Tumors.  Vascular  Nevi. — These  are  either  con- 
genital or  develop  soon  after  birth,  and  are  found  in  the  vast  majority 
of  cases  about  the  head.  It  is  the  prognosis  and  treatment,  rather  than 
the  diagnosis,  that  is  of  the  greatest  interest  to  the  surgeon,  for  the 
diagnosis  is  easy  except  in  those  deep  cases  occurring  primarily  in  the 
bone  or  its  covering. 

Angiomas. — Some  of  the  simple  angiomas,  or  port-wiyie  staim,  dis- 
appear spontaneously.    This  is  noticeable  chiefly  in  the  flat  variety,- 


PLATE    1 


Multiple  Nevl,  Affecting  Scalp,  Forehead,  Left  Foot,  etc.,  in  a 
Baby  Aged  two  and  one-half  Months.  Episcopal  Hospital. 
(Ashhurst.) 


288     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

of  the  new  gro\s'th  do  not  offer  the  resistance  of  the  normal  skin  which 
overlies  the  venous  or  arterial  angiomata,  and  may  break  dowTi  under 
the  hot  water.  In  all  of  my  cases  the  scarring  has  been  very  slight,  and 
I  think  the  method  is  well  worthy  of  thorough  trial  in  these  cases.  As 
they  occur  chiefly  in  children  and  are  situated  on  the  face,  it  is  important 
to  have  the  patient  very  firmly  held  while  the  injections  are  being  made 
without  narcosis.  The  legs,  arms,  body  and  head  should  be  kept 
immovable,  while  the  face  should  be  covered  by  a  mat  in  which  an 
aperture  is  cut  sufficient  to  expose  the  area  to  be  injected.  I  take  the 
additional  precaution  to  have  an  assistant  hold  a  sponge  saturated 
with  cold  water  immediately  over  the  needle  in  order  to  prevent 
scalding  the  cuticle  should  the  apparatus  leak.  The  small  hj^Dodermic 
needle  is  used,  and  this  should  be  thrust  through  the  sound  skin, 
about  one-eighth  of  an  inch  from  the  edge  of  the  angioma,  pushed 
beneath  the  neoplasm,  care  being  taken  not  to  let  the  point  come 
through  the  surface.  From  5  to  15  minims  of  water  may  be  injected  in 
one  spot,  changing  the  needle  here  and  there  to  suit  the  size  of  the  mass. 
When  the  injections  are  made  directly  into  the  enlarged  capillaries, 
necrosis  almost  always  occurs,  but  if  the  water  is  forced  well  beneath 
the  surface,  the  deeper  parent  vessels  vnW  be  coagulated,  causing  the 
ne\'us  to  disappear  by  gradual  denutrition  (granular  metamorphosis). 
It  is  a  wise  precaution  to  cover  the  area  injected  at  once  with  aseptic 
collodion  to  prevent  infection.  This  operation  may  be  repeated  from 
time  to  time  until  a  cure  is  effected." 

The  simple  angiovias  or  port-wine  stains  that  are  too  large  for  oper- 
ative treatment  may  be  treated  with  the  carbon  dioxide  snow.  W,  A. 
Pusey,^  states  that  "  The  most  useful  field  for  the  agent  (Solid  Carbon 
Dioxid)  is  in  the  treatment  of  nevi,  both  pigmentary  and  vascular. 
Moles,  which  are  small  pigmented  ne\i.,  you  can  get  rid  of  early  by 
freezing  two  or  three  times  from  half  a  minute  to  a  minute.  With  pig- 
mented nevi  up  to  the  size  of  a  coin  you  can  usually  get  practically 
perfect  results.  With  large  nevi  the  results  are  only  relatively  good,  but 
better  than  by  any  other  method. 

"In  the  flat  ne^^,  port-wine  marks,  where  there  is  simply  a  red  dis- 
coloration of  the  skin,  you  cannot  get  as  good  results  as  in  cases  where 
there  is  an  excess  of  tissue  to  work  on.  In  these  lesions  up  to  the  size 
of  a  coin  in  young  children  I  have  been  able  to  get  excellent  results, 
but  in  the  larger  lesions  the  results  are  not  as  good  as  can  be  gotten  with 
radium  or  .r-rays  or  with  these  combined  w^th  carbon  dioxid.  In  small 
elevated  nevi,  no  matter  how  cavernous,  one  can  usually  get  almost 
perfect  results,  especially  when  treating  young  children." 

The  snow  is  collected  in  chamois  skin  bags  or  in  some  mechanical 
contrivance  and  formed  into  sticks  or  pencils  of  the  desired  size.  The 
degree  of  pressure  and  the  duration  of  the  freezing  determine  the 
amount  of  reaction.    The  time  of  freezing  varies  from  five  seconds  to  a 

1  The  Therapeutic  Application  of  Solid  Carbon  Dioxid.  111.  Med.  Jour.,  February, 
1912. 


TUMORS  OF  THE  SCALP 


289 


minute  or  more.  The  tissues  in  children  are  naturally  more  sensitive 
and  require  the  minimum  amount  of  exposure.  With  an  application  of 
ten  seconds'  duration  in  children  you  get  as  much  reaction  as  with  thirty 
seconds  in  adults.  Pusey  advises  caution  in  treating  the  terminal  areas 
of  circulation,  as  the  borders  of  the  ear,  the  bridge  of  the  nose,  the 
extremities,  particularly  the  legs. 


Fig.  61. — Epithelioma  of  soalp.  Chronic  sloughing  ulcer,  irregular  in  outline,  with 
elevated  borders  and  infiltrated  reddened  areola.  Six  months'  duration.  Second  point 
of  ulceration  beginning  at  lower  periphery  of  the  neoplasm.      (Martin.) 


Malignant  Growths. — Malignant  growths  of  the  scalp  may  be 
primary  or  secondary.  The  primary  cancers  are  either  chronic  super- 
ficial epitheliomas  or  deep  aggressive  tmnors. 

The  superficial  cancers,  epitheliomas  or  rodent  ulcers  are  not  rare  on 
the  scalp,  and  are  more  frequent  than  the  deep  variety.  They  are 
found  almost  entirely  in  advanced  or  middle  life,  and  develop  as  a  rule 
on  some  preexisting  benign  lesion,  such  as  a  wart,  mole,  adenoma,  or  a 

VOL.  I 19 


290     INJURIES  AND  DISEASES  OF  SKULL -AND  ITS  COVERINGS 

sebaceous  or  sweat  gland,  old  ulcer  or  senile  seborrhea.  Chronic  irri- 
tation of  one  of  these  latter  lesions  seems  to  be  the  cause  of  the  malignant 
degeneration  in  most  cases.  Some  cases  develop  in  apparently  normal 
skin,  without  a  preexisting  lesion.  The  forehead,  in  the  region  of  the 
eye  or  temple,  is  the  favorite  location.  The  breaking  down  of  the  first 
small  nodule  in  the  skin  results  in  an  ulcer  which  is  shallow  and 
unevenly  rounded,  and  which  has  a  more  or  less  indurated  border. 
This  border  may  be  slightly  elevated,  une^•en  and  somewhat  under- 
mined.    The  surface  usually  bleeds  on  slight  irritation.     There  is  a 


Fig.  62. — Superficial  epithelioma  of  the  scalp.      (Hertzler.) 

tendency  at  times  for  the  ulcer  to  become  covered  temporarily  with 
epidermis,  and  sometimes  scar  tissue  forms  to  such  an  extent  as  to 
draw  the  surrounding  skin  into  folds.  In  the  early  stages,  even  for 
years,  the  ulcer  may  be  freely  movable  with  the  skin,  but  later,  with 
deeper  invasion,  it  becomes  fixed. 

While  these  cases  are  chronic  from  the  beginning,  and  sometime  are 
small  at  the  end  of  five  or  ten  years,  with  no  apparent  metastases,  they 
may  at  any  time  become  vicious  and  rapidly  invade  the  surrounding 
structures,  destroying  even  the  underlying  bone. 


TUMORS  OF  THE  SCALP  291 

The  deep  cancer  while  less  frequent  on  the  scalp  than  the  superficial 
is  a  much  more  formidable  t}-pe  of  tumor,  as  it  quickly  invades  the 
surrounding  tissues  in  all  directions,  and  early  spreads  to  the  neighbor- 
ing h-mph  nodes  and  to  more  distant  parts  of  the  body.  In  this  A-ariety 
the  tumor  element  is  a  prominent  feature  from  the  beginning  and 
ulceration  is  often  deep. 

Skin  cancer  sometimes  grows  as  a  papillanj  timior,  originating  either 
in  a  preexisting  benign  wart,  or  developing  as  a  malignant  papilloma 
from  apparently  normal  skin.    Horns  may  be  present  in  these  cases. 

Differential  Diagnosis.^The  differential  diagnosis  of  the  skin  cancers 
calls  for  a  consideration  of  syphilitic  and  tuhercidous  ulcerations,  and 
sometimes  the  ulcers  oi  blastomycosis.  In  the  latter  three  conditions 
the  lesions  are  usually  multiple,  and  they  lack  the  induration  so  char- 
acteristic of  most  cancers.  For  further  details  see  special  headings. 
The  Wassermann  and  tuberculin  tests  are  helpful  here;  and  the  finding 
of  the  blastomyces  in  the  smears  would  settle  the  diagnosis  in  the  case 
of  blastomycosis.  Too  often  it  is  the  change  in  character  which  a 
preexisting  benign  lesion  has  assumed  that  is  misunderstood.  It  is  a 
singular  fact  that  cancers  on  the  surface  of  the  body,  where  they  can  be 
seen  and  felt,  are  very  frequently  allowed  to  progress  to  an  incurable 
stage  before  the  correct  diagnosis  is  made.  "\Mien  a  wart  begins  to  grow 
larger  or  ulcerates,  or  when  nodules  develop  in  a  chronic  ulcer,  malig- 
nancy should  always  be  suspected,  and  a  positive  diagnosis  made  at 
once. 

In  all  doubtful  cases,  and  these  are  usually  the  early  cases,  the  lesion, 
if  not  too  large,  should  be  completely  excised,  and  the  diagnosis  made 
from  the  frozen  section.  If  the  surface  ulceration  is  quite  extensive 
and  the  diagnosis  still  in  doubt,  excision  of  a  suspicious  piece  will  allow 
the  diagnosis  to  be  made  from  the  frozen  section,  the  woimd  in  the 
meantime  being  packed  with  Harrington's  solution  No.  9. 

Treatment. — The  treatment  for  skin  cancer  is  complete  excision  of  the 
growth  and  the  hiiiph  nodes  most  likely  to  be  involved.  The  latter 
should  be  excised  en  masse,  with  the  surrounding  fat,  regardless  of 
whether  they  are  palpable  or  not.  It  is,  however,  impossible  to  deal 
thus  radically  with  the  parotid  hmph  nodes  unless  one  is  willing  to 
sacrifice  the  facial  nerve.  INIany  cases  confined  entirely  to  the  skin, 
and  without  glandular  involvement,  have  been  apparently  cm-ed  by  the 
use  of  the  a;-rays  or  radium,  but  most  of  these  could  have  been  excised 
without  resulting  deformity.  In  inoperable  cases  the  ar-ray,  radium, 
caustic  pastes  and  the  cautery  will  often  be  of  some  serA-ice  in  retarding 
the  superficial  growth  and  in  keeping  do\Mi  hemorrhage  and  infection. 

Sarcoma  of  the  Scalp. — Sarcoma  of  the  scalp  may  occur  at  any  age 
or  in  any  region.  It  may  be  primary  in  the  connective  tissue  of  the 
apparently  normal  skin  or  fascia,  but  it  usually  arises  secondarily  in 
warts,  moles  or  vascular  ne^-i.  Grossly  they  are  diA-ided  into  two 
groups:  The  nodidar,  aggressive  tumor  which  infiltrates  the  surround- 
ing tissues,  and  the  icarty  tA-pe,  which  grows  more  as  a  papilloma.  The 
nodular  t^-pe  may  or  may  not  be  markedly  elevated  above  the  surround- 


292     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

ing  skin  surface,  haxdng  edges  in  some  cases  like  a  mushroom,  but  it  is 
always  a  more  or  less  formidable  tumor  invading  the  surrounding  tissue 
and  leading  to  extensive  metastases  to  the  nearest  hnnph  glands  and 
to  the  various  organs  of  the  body.  The  overlying  skin,  especially  in  the 
deeper  varieties,  may  remain  intact  for  a  long  time.  If  ulceration  occurs 
it  is  more  superficial  and  smooth,  rather  than  deep  and  crater-like  as  in 
carcinoma. 


r 

^ 

■ 

1 

■-Jl^ 

w 

^^^^^H 

\ 

jjl 

Fig.  63. — Sarcoma  of  scalp.     Death  a  few  months  after  photograph  was  made. 
(Dr.  W.  L.  Rodman's  case.)      Presbyterian  Hospital.     (Ashhurst.) 


T  /' 


Fig.  64. — Endothelioma  of  the  scalp.     (Hertzler.) 


The  icarty  sarcomas  present  themselves  as  bleeding  fleshy  warts, 
whether  they  develop  primarily  as  such  or  secondarily  in  a  papilloma. 
They  are  found  chiefly  in  ad^■anced  life  and  their  clinical  course  is  much 
more  benign  than  that  of  the  nodular  variety. 


WOUNDS  OF  THE  CRANIAL  BONES  293 

Melanosarcoma,  arising  from  a  pigmented  mole,  is  in  a  class  by  itself 
because  of  its  viciously  malignant  course.  It  may  develop  as  a  very 
aggressive  nodular  mass  or  as  multiple  pigmented  nodules  in  the 
skin,  in  any  event  leading  to  early  metastases  through  the  lymph  and 
blood  channels  to  the  glands,  viscera,  bones  or  skin.  The  'pigment  in 
both  the  original  tumor  and  the  metastases  is  the  striking  feature. 

Angiosarcoma,  which  may  exist  as  a  relatively  hard  tumor  or  as  a 
soft  'pulsating  variety,  may  arise  from  the  endo-  or  perithelial  cells  of 
hypertrophied  bloodvessels. 

Endothelioma,  i.  e.,  lymphangio-endothelioma,  is  not  only  rare  in  the 
scalp,  but  it  is  impossible  to  recognize  it  clinically.  It  consists  of  a  slow- 
growing  circumscribed  nodule  with  very  little  tendency  to  metastasis 
and  hence  is  a  relatively  benign  tumor. 

Diagnosis.— Sometimes  it  is  necessary  to  differentiate  sarcoma  from  a 
rapidly  developing  gumma. 

Prognosis. — The  prognosis  of  the  above  mentioned  forms  of  sarcoma 
varies  according  to  the  type  of  tumor  we  are  dealing  with.  The  type 
described  as  nodular  offers  a  very  bad  prognosis,  the  warty  variety  a 
relatively  good  prognosis,  while  in  melanosarcoma  and  all  very  vascular 
sarcomas  the  outlook  is  exceedingly  bad.  Endotheliomas  are  relatively 
benign. 

Treatment. — The  treatment  in  all  cases,  if  not  inoperable,  is  wide 
excision.  In  the  inoperable  cases,  and  in  certain  postoperative  cases,  it 
is  well  to  try  the  a;-ray,  and  also  Coley's  mixture  of  the  toxins  of 
erysipelas  and  bacillus  prodigiosus.  The  x-ray  should  be  intensive 
and  should  be  given  daily  for  a  period  of  six  days.  This  procedure 
should  be  repeated  every  few  weeks  for  a  period  of  several  months. 


THE  CRANIAL  BONES. 

WOUNDS  OF  THE  CRANIAL  BONES. 

Wounds  of  the  cranial  bones  are  usually  classified  as  incised,  punc- 
tured and  contused  ivounds.  Naturally  the  character  of  the  wound  will 
depend  to  a  great  extent  upon  the  shape  and  size  of  the  contusing 
surface,  as  well  as  upon  the  force  and  direction  of  the  blow. 

Incised  Wounds. — ^A  saber  cut,  or  a  blow  with  the  sharp  edge  of  a 
hatchet,  if  delivered  with  force  squarely  on  the  vault,  may  result  in  an 
incised  wound  of  the  bone  with  no  surrounding  fragmentation  or  frac- 
ture, except  possibly  a  fissure  extending  out  from  either  end  of  the  cut. 
The  same  blow,  with  less  force,  may  cause  an  incised  wound  of  the 
outer  table  with  more  or  less  fragmentation  of  the  inner  table.  A 
powerful  blow  with  the  same  instrument  in  a  tangential  direction  may 
slice  off  a  flap  of  bone.  Though  these  cases  are  all  open  to  inspection 
it  is  sometimes  difficult  to  determine  accurately  the  extent  of  injury 


294     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

to  the  internal  table  or  the  underlying  soft  ])arts.  The  prognosis 
depends  not  only  upon  the  latter,  but  upon  the  presence  or  absence  of 
infection. 

If  the  history  of  the  injury,  the  appearance  of  the  wound,  and  the 
lack  of  symptoms  make  it  reasonably  certain  that  the  wound  is  non- 
penetrating, disinfection,  partial  suture  and  drainage  of  the  wound, 
is  probably  all  that  is  necessary.  If  the  w^ound  has  penetrated  the 
cranium,  disinfection,  trephining,  removal  of  foreign  bodies  and  drain- 
age are  always  indicated.  The  drainage  should  extend  through  the 
dura  if  the  latter  has  been  opened. 


Fig.  65. — Sword  cut;  fissured  fracture. 

Punctured  Wounds. — Punctured  wounds  are  similar  to  incised 
wounds  in  many  respects,  with  these  differences,  however:  that  they 
are  not  so  freely  open  to  inspection,  and  that,  if  not  operated,  drainage 
is  poor.  Consequently  they  are  more  liable  to  serious  deep  infections. 
Moreover,  the  penetrating  body  is  liable  to  be  broken  off. 

Every  case  calls  for  early  disinfection,  trephining,  removal  of  foreign 
bodies  and  drainage.  The  drain  should  always  extend  to  the  cortex  if 
the  dura  is  not  intact. 

Contusions. — A  subcutaneous  contusion  of  the  skull  always  carries 
-^-ith  it  the  question  as  to  whether  one  is  dealing  with  a  contusion  or  a 
fracture. 

Diagnosis.- — In  making  a  probable  diagnosis  one  has  to  consider  the 
force  and  direction  of  the  blow^  and  the  size  of  the  contusing  surface, 
as,  for  instance,  a  swift  blow  from  a  body  with  a  small  surface,  like  a 
hammer,  delivered  squarely  on  the  head,  is  very  likely  to  have  caused 
a  fracture.  Under  such  circumstances  one  is  justified  in  making  an 
accurate  diagnosis  by  inspection  and  palpation  through  an  exploratory 
incision.  On  the  other  hand,  with  the  history  of  a  less  severe  blow, 
especially  if  delivered  on  a  tangent,  and  in  the  absence  of  intracranial 
SATiiptoms,  expectant  treatment  may  be  all  that  is  called  for.  One 
should  always  be  on  his  guard  lest  he  be  led  into  the  diagnosis  of 


WOUNDS  OF  THE  CRANIAL  BONES  295 

depressed  fracture  by  the  firm  ring  of  reactionary  edema  so  often 
noticed  in  contusions  with  hemorrhage  into  the  soft  external  coverings. 
Distinct  intracranial  symptoms,  such  as  those  of  compression,  will 
demand  active  exploration  even  though  the  injury  itself  has  the 
appearance  of  being  a  simple  contusion. 

Prognosis. — The  prognosis  in  all  head  injuries,  especially  in  those  of 
advanced  years,  and  in  those  with  distinctly  bad  family  histories,  from 
the  standpoint  of  the  central  nervous  system,  should  allow  for  possible 
subsequent  mental  symptoms,  epilepsy,  etc. 

Osteomyelitis  may  possibly  develop  later  on  as  a  result  of  diminished 
local  resistance,  but  this  is  not  very  frequent. 


Fig.  66. — Fissured  fracture,  a;-ray  findings  confirmed  at  operation.   (H.  P.  Knapp.) 


Skull  Fractures. — The  diagnosis  of  a  fracture  of  the  skull  in  the 
absence  of  an  open  wound,  is  sometimes  exceedingly  difficult,  or  even 
impossible.  A  fracture  may  exist  without  bony  deformity  and  with 
no  symptoms  referable  to  the  brain  or  cranial  nerves.  On  the  other 
hand  cerebral  symptoms  may  follow  an  injury  to  the  skull  without 
fracture;  hence  they  have  more  to  do  with  prognosis  than  diagnosis. 
Tumefaction  of  the  scalp  may  completely  obliterate  an  underlying 
depression,  and  even  palpable  depressions  may  not  be  of  recent  origin. 
In  the  latter  case  an  unconscious  patient  could  not  explain  that  his 


296     IX JURIES  AXD  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

depression  was  due  to  an  old  injury,  disease  or  deformity.  Contusion 
with  hemorrhage  into  the  soft  coverings  and  certain  infections  in  the 
scalp  may  so  closely  simulate  fracture  with  depression  as  to  deceive 
capable,  but  somewhat  careless,  diagnosticians.  A  contusion  at  one 
point  may  lead  to  a  fracture  or  cerebral  involvement  at  another  point. 
The  .T-ray  examinations  may  be  of  great  assistance,  and  even  the 
careful  use  of  the  stethoscope,  combined  with  percussion,  is  considered 
by  some  as  being  helpful  in  some  cases. 

It  is  no  longer  permissible  to  explore  every  simple  contusion  merely 
to  determine  the  existence  of  a  fracture.  The  exploratory  incision  is  to 
be  made  on  the  grounds  of  cerebral  injury  rather  than  those  of  fracture, 
except  possibly  in  those  cases  where  the  history  of  the  injury,  combined 
with  suggestive  local  findings,  render  it  probable  that  a  bending 
fracture  has  occurred. 


Fig.  67. — Fracture  of  vault.      (Hartung  and  Huber.) 

Palpation  and  the  a*-ray  are  practically  our  only  means  of  diagnosing 
simple,  or  closed,  fractures.  For  this  reason  the  uncomplicated  fissured 
fracture  wdll  often  go  unrecognized.  A  probable  diagnosis  of  this  con- 
dition would  be  made  if  there  existed  a  persistent  tenderness  along 
a  definite  line,  especially  if  the  pain  were  noticeable  on  both  direct 
and  indirect  pressure.  Such  a  diagnosis,  however,  would  be  of  little 
consequence. 

If,  following  an  injury,  there  were  found  under  the  scalp  a  collection 
of  fluid  that  pulsated  with  the  brain,  and  which  also  became  tense  with 
increased  intracranial  tension,  as  in  coughing,  crying,  sneezing,  etc., 


nOVXDS  OF  THE  CR AXIAL  BOXES 


297 


a  fracture  with  rupture  of  the  dura  would  be  diagnosed.    The  fluid 
might  be  blood  or  cerebrospinal  fluid.    The  latter  is  most  frequently 


FiG._68. — Circumscribed  depressed  fracture,  outer  surface. 

found  in  the  fractures  of  the  infant  cranium,  and  is  spoken  as  a  meningo- 
cele spuria.  LikeT\^se  a  collection  of  air  beneath  the  pericranium, 
pneumatocele  capitis,  follomng  injury,  means  fracture  tlirough  an  air- 
containing  sinus. 


Fig.  69. — Circumscribed  depressed  fracture,  inner  surface. 

The  simple  depressed  and  comminuted  fractures  of  the  vault  can 
usually  be  easily  recognized  by  palpation  alone,  especially  if   seen 


298     INJURIES  AXD  DISEASES  OF  SKULL  AXD    ITS  COVERINGS 

directly  after  the  injury.  As  stated  in  a  previous  paragraph  the  history 
of  the  accident,  combined  with  suggestive  local  findings,  will  often 
make  the  existence  of  a  fracture  most  probable.    Thus  when  a  patient 


Fig.  70. — Circumscribed  fracture  with  inclusion  of  hair. 

receives  a  powerful  blow  w^th  a  hammer  squarely  on  the  Aault  a  bend- 
ing fracture  with  comminution  of  the  internal  table  is  almost  certain 
to  be  present. 


Fig.  71. — Circumscribed  depressed  fracture. 


Compound  fractures  of  the  vault  with  anything  more  than  a  small 
skin  wound  will  usually  be  both  visible  and  palpable.  The  only  danger 
here  would  lie  in  carelessly  mistaking  a  rough  suture  line,  Wormian 
bones,  senile  atrophy  or  the  irregularities  of  an  old  osteomyelitis  for 
fracture. 


WOUNDS  OF  THE  CRANIAL  BONES 


299 


Having  made  a  diagnosis  of  fracture  of  the  external  table,  whether 
simple  or  compound,  it  is  not  always  possible  to  know  definitely  whether 
the  internal  table  is  fractured  or  not.  Most  of  the  fissures  involve  both 
tables,  and  all  steep  depressions,  except  possibly  those  over  the  air- 


FiG.  72. — Fracture  of  internal  table. 


containing  sinuses,  not  only  involve  the  inner  table,  but  the  latter  is 
broken  more  extensively  than  the  outer  table.  Punctured  fractures 
practically  always  involve  both  tables,  the  inner  more  than  the  outer. 
Gunshot  injuries  will  be  mentioned  later.    Fracture  of  the  internal  table 


Fig.  73. — Teevan's  diagram  to  show  that  the  inner  table  often  is  more  extensively 
damaged  than  the  external,  because  it  is  in  the  line  of  extension.     (Ashhurst.) 

alone  is  to  be  surmised  when  a  sharp  local  impact  over  an  area  where 
diploe  exists,  though  showing  no  external  fracture,  results  in  local 
cortical  irritation.  A  good  skiagram  might  possibly  establish  a  positive 
diagnosis. 


300     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

Fractures  of  the  Base. — Basal  fractures  are  in  a  class  by  themselves 
because  of  the  mechanism  of  their  production,  their  serious  nature,  the 
fact  that  they  nearly  always  traverse  some  cavity  containing  infectious 
germs,  and  because  of  the  fact  that  the  fracture  cannot  be  palpated. 
The  symptoms  on  which  the  diagnosis  is  based  are  mostly  indirect. 

The  contusing  violence  here  is  of  a  diffuse  character,  i.  e.,  instead 
of  the  sharp  impact  over  a  small  surface  as  we  find  in  bending  fractures, 
the  force  is  more  of  a  crushing,  compressing  violence,  covering  a  broader 
area  and  tending  to  press  the  poles  of  the  skull  together.  As  examples 
of  such  violence  one  might  mention  a  blow  from  a  falling  timber,  a 
fall  from  a  height  striking  on  the  head,  etc.  Any  force  which  presses 
the  opposite  poles  together  tends  to  burst  the  skull  along  the  lines  of 
the  meridians.    The  direction  of  the  meridian  or  fracture  depends  upon 


Fig.  74. 


-Diagram  showing  the  usual  course  taken  by  fissured  fractures  of  the  base 
of  the  skull. 


the  direction  of  the  force  or  compression.  As  the  base  of  the  skull  offers 
the  least  resistance  to  this  bursting  effect,  the  line  of  fracture  will  be 
found  more  frequently  here  than  over  the  vault. 

Symptoms.^ — As  to  the  symptoms  which  lead  us  to  infer  that  a 
fracture  of  the  base  has  occurred,  one  of  the  most  important  is  hemor- 
rhage, free  or  into  the  tissues,  with,  however,  definite  qualifications. 
Bleeding  may  occur  freely  into  thie  nose  or  nasopharynx  or  through  the 
ear.  Here  it  is  necessary  to  exclude  local  injury  to  the  nose,  mouth  and 
throat  or  to  the  extracranial  parts  of  the  ear.  Very  slight  injuries  may 
cause  bleeding  from  the  nose,  especially  in  certain  individuals,  but  if 
the  hemorrhage  from  the  parts  is  associated  exclusively  with  injury  to 
some  part  of  the  cranium,  it  takes  on  a  distinct  significance.  The  bleed- 
ing from  the  nose  in  cases  of  fracture  of  the  anterior  fossa  comes 
usually  from  a  break  through  the  ethmoid,  while  in  middle  fossa  frac- 


WOUNDS  OF  THE  CRANIAL  BONES  301 

tures  it  generally  comes  through  the  sphenoid  sinus.  In  some  cases 
it  reaches  the  nasal  cavity  through  the  Eustachian  tube,  having  come 
from  a  fracture  through  the  middle  ear  without  rupture  of  the  drum. 

When  considering  the  local  causes  of  hemorrhage  from  the  nose  and 
nasopharynx  one  must  remember  the  possibility  of  penetrating  wounds 
of  the  base  resulting  from  falls  upon  a  pointed  stick  or  weapon. 

A  free  hemorrhage  from  the  ear  in  case  of  injury  to  some  other  part 
of  the  skull  is  probably  due  to  a  fracture  of  the  base  involving  the 
middle  ear,  usually  with  rupture  of  the  drum  membrane,  though  the 
latter  may  remain  intact,  the  blood  then  escaping  through  the  roof  of 
the  canal.  A  very  mild  hemorrhage  following  a  direct  trauma  may 
mean  merely  injury  of  the  extracranial  parts  of  the  ear. 

Hemorrhage  into  the  tissues  may  be  due  to  a  contusion  without 
fracture,  as  seen  in  the  ordinary  black  eye,  or  it  may  follow  a  fracture. 
In  the  former  case  it  appears  as  a  black  and  blue  swelling  promptly 
after  the  injury,  whereas  in  the  case  of  fracture  it  makes  its  appearance 
late,  at  least  hours  afterward,  but  usually  one  or  two  days  after  the 
injury. 

Ecchymosis  in  or  about  the  orbit,  like  hemorrhage  into  the  nose,  may 
result  immediately  from  slight  local  injuries,  or  from  straining,  as  in 
severe  fits  of  coughing,  but  if  due  to  fracture  it  comes  not  only  late,  but 
is  more  extensive.  If  a  large  vessel,  like  the  cavernous  sinus  or  the 
orbital  branch  of  the  middle  meningeal,  were  ruptured,  the  infiltra- 
tion of  the  tissues  and  the  appearance  of  the  ecchymosis  would  be 
more  rapid.  According  to  the  location  of  the  fracture  the  ecchymosis 
may  appear  in  the  upper  lid,  beneath  the  conjunctiva,  or  in  the  retro- 
bulbar fat.  In  the  latter  case  exophthalmus  might  be  a  result,  the 
degree  and  the  time  of  appearance  depending  upon  the  amount  of 
hemorrhage  and  the  size  of  the  vessel  involved.  Pulsating  exophthalmus 
with  the  eyeball  pushed  outward  as  well  as  forward,  would  indicate 
injury  of  both  the  internal  carotid  and  cavernous  sinus  with  a  resulting 
arteriovenous  aneurysm.  In  this  event  the  other  signs  of  arteriovenous 
aneurysm  would  be  present. 

Ecchymosis  appearing  in  the  region  of  the  mastoid  or  temple  several 
days  after  a  head  injury  is  usually  indicative  of  a  fracture  of  the  middle 
fossa;  likewise  a  late  appearing  ecchymosis  in  the  occipital  region  or 
neck  may  point  to  fracture  of  the  posterior  fossa. 

Unquestionable  signs  of  fracture  are  the  escape  of  cerebrospinal  fluid 
and  brain  substance.  The  latter  is  found  only  in  case  of  severe  frac- 
tures, while  the  former  may  occur  in  either  the  mild  or  severe  cases. 
The  cerebrospinal  fluid  has  been  noticed  in  only  about  5  per  cent,  of 
cases  of  fracture  of  the  base.  It  may  be  small  in  amount  or  very  free. 
In  one  of  my  cases  the  escape  was  so  free  that  large  sterile  pads  had  to 
be  kept  over  his  ear.  During  coughing  or  sneezing  the  fluid  was  noticed 
on  several  occasions  to  spurt  a  distance  of  two  feet  from  the  patient. 
The  peculiar  feature  of  this  case  was  that  the  young  man,  who  had  been 
thrown  from  a  delivery  wagon,  striking  on  his  head,  sustained  only  a 
moderate  concussion,  and  scarcely  felt  sick  enough  to  remain  in  bed. 


302     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

In  this  particular  case  the  fluid  was  noticed  promptly  after  the  accident, 
though  in  the  ordinary  case  it  is  not  noticed  until  hours  afterward,  at 
any  rate  not  until  the  free  hemorrhage  clears  up.  It  may  make  its 
first  appearance  days  after  the  injury.  The  flow  may  last  from  a  few 
hours  to  a  week  or  more.  Cerebrospinal  fluid,  like  hemorrhage  in  basal 
fractures,  may  find  its  way  into  the  nose  through  fractures  of  the 
ethmoid  or  sphenoid,  or  it  may  come  do"s\'n  the  Eustachian  tube  from 
the  ear.  It  contains  large  quantities  of  chlorides,  but  no  albumin 
unless  mixed  with  blood  or  exudates.  The  exudates,  on  the  other 
hand,  contain  only  a  small  amount  of  chlorides,  while  they  possess  a 
comparatively  large  amount  of  albumin.  If  the  quantity  of  clear  fluid 
escaping  from  either  the  ear  or  nose  is  small  its  source  cannot  be  deter- 
mined without  a  chemical  examination.  If  it  is  large,  and  especially 
if  the  rate  of  flow  depends  upon  the  variations  of  intracranial  pressure, 
there  can  be  no  question  about  its  being  cerebospinal  fluid. 

Symptoms  due  to  involvement  of  the  cranial  nerves  possess  only  a 
relative  diagnostic  value  because  they  may  represent  either  a  peripheral 
or  central  lesion  with  or  without  fracture.  They  are  often  of  distinct 
service,  however,  in  locating  the  seat  of  fracture,  especially  if  the 
grouping  of  the  s\Tnptoms  is  studied.  Thus  paralysis  of  the  seventh, 
eighth  and  sixth  nerves  determines  the  course  of  the  fracture  through 
the  petrous  process  (von  Bergmann).  The  time  of  the  onset  of  the 
s\'mptoms,  and  the  extent  of  the  paralysis,  will  materially  aid  in  estab- 
lishing the  nature  of  the  lesion,  whether  rupture,  compression  from 
hemorrhage  or  inflammatory  exudate,  etc.  The  nerve  most  frequently 
involved  is  the  facial  because  it  traverses  a  long,  tortuous  canal  in 
the  petrous  process  which  is  so  often  the  seat  of  fracture.  The  sixth 
ranks  next  to  the  facial  in  frequency  of  involvement.  In  fractures  of 
the  anterior  fossa  the  nerve  most  frequently  injured  is  the  olfactory 
because  of  the  usual  involvement  of  the  fragile  cribriform  plate  of  the 
ethmoid.  The  second  and  third  nerves,  and  the  first  division  of  the 
fifth  may  be  more  or  less  involved.  In  middle  fossa  fractures  the  nerve 
most  frequently  injured  is  the  seventh.  As  stated  before,  the  eighth  is 
frequently  implicated  with  the  seventh.  The  second  and  third  divisions 
of  the  fifth  nerve  are  seldom  injured.  Fractures  through  the  cavernous 
sinus  may  in^-olve  the  first  di^-ision  of  the  fifth,  the  sixth,  third  and 
fourth  nerves.  In  fractures  of  the  posterior  fossa,  involving  the 
jugular  foramen,  the  ninth,  tenth  and  eleventh  nerves,  which  pass 
through  this  foramen,  are  only  occasionally  injured. 

Fracture  of  the  base  is  often  associated  with  fracture  of  the  vault, 
probably  in  about  three-fourths  of  the  latter;  and  fissure  of  the  vault 
is  frequently  found  in  cases  where  the  basal  injury  predominates.  The 
character  of  the  injury,  whether  a  localized  sharp  impact  or  a  diffused 
compression,  is  a  decided  factor  in  the  determination  of  the  kind  of 
fracture,  whether  bending  or  bursting.  The  location  of  the  impact 
and  the  direction  of  the  force  determines  to  a  great  extent  the  general 
direction  of  the  line  of  fracture.  For  these  reasons  a  detailed  history 
of  the  accident  can  often  be  of  distinct  assistance  in  the  diagnosis. 


WOUNDS  OF  THE  CRANIAL  BONES  '  303 

After  all,  the  diagnosis  of  fracture  in  its  various  forms  and  locations 
is  of  service  only  insofar  as  it  enables  the  surgeon  to  recognize  and  treat, 
or  to  prevent,  associated  lesions  of  the  intracranial  structures.  The 
important  features,  therefore,  i.  e.,  lesions  of  the  brain,  its"  coverings, 
etc.,  will  be  discussed  later  on  under  their  proper  headings. 

Prognosis. — The  gravity  of  skull  fractures  can  be  appreciated  when 
one  realizes  that  approximately  one-third  of  all  cases  prove  fatal, 
largely  because  of  the  violence  to  the  Intracranial  structures.  As 
practically  all  basal  fractures  and  the  majority  of  vault  fractures  are 
compound,  the  possibilities  of  early  or  late  infection,  thromboses,  etc., 
become  manifest.  Then,  too,  there  is  always  the  remote  possibility  of 
degenerations,  cortical  irritations,  etc.,  leading  to  epilepsy,  insanity 
and  the  various  neuroses.  The  prognosis  then  depends  to  a  great 
extent  upon  the  surgeon's  ability  to  cope  with  the  existing  conditions 
and  upon  his  ability  to  prevent  the  remote  pathology.  His  unavoidable 
limitations  in  these  respects,  especially  in  basal  as  compared  with  vault 
fractures,  can  be  better  imagined  than  described. 

Rawlings  in  a  study  of  the  records  of  over  300  cases  came  to  the 
conclusion  that  the  temperature  chart  of  the  patient  is  of  great  value 
in  formulating  a  prognosis  in  cases  of  head  injuries.  He  concludes  that 
for  a  variable  period  of  time  after  the  injury  the  temperature  is  sub- 
normal, this  being  the  period  of  shock.  Death  may  occur  during  this 
period,  or  reaction,  accompanied  by  a  rise  of  temperature,  may  set  in. 
If  the  temperature  remains  normal  the  prognosis  is  good.  If  it  rises 
moderately  and  then  ''marks  time"  the  prognosis  is  held  in  abeyance 
as  the  case  has  reached  its  crisis;  a  fall  to  normal  now  indicates  a 
recovery,  while  a  further  rise  usually  points  to  a  fatal  termination.  A 
rapid  and  progressive  rise  of  temperature  (6°  or  8°  in  a  few  hours)  is 
usually  an  indication  of  early  fatal  termination.  Laceration  of  the 
brain  was  present  in  the  majority  of  cases  with  marked  temperature. 

Treatment. — The  treatment  of  all  of  these  cases  has  for  its  object  the 
conservation  of  the  functions  of  the  brain  rather  than  any  special 
treatment  of  the  bony  lesion  itself. 

In  simple  fractures  of  the  vault  interference  is  warranted  (a)  on 
definite  indications  of  bony  deformity,  such  as  depression  regardless  of 
symptoms,  ih)  by  the  evidence  of  localized  compression  whether  extra- 
dural or  intradural,  (c)  by  the  evidence  of  localized  cortical  irritation. 
In  special  cases  subdural  drainage  may  be  indicated  on  the  grounds  of 
general  compression  in  case  of  edema.  Those  cases  associated  with 
contusion  and  general  cerebral  irritation  do  not  call  for  operation. 
In  any  case  operation  should  not  be  performed  during  profound 
shock. 

All  corn-pound  fractures  of  the  vault  are  operative,  if  for  no  other  reason 
than  primary  wound  disinfection.  Especially  is  this  the  case  in  punc- 
tured fractures,  for  evident  reasons.  In  all  these  cases  adequate  drain- 
age to  the  cortex  or  dural  opening  is  indicated,  and  free  drainage  must 
likewise  be  provided  for  the  bhnd  pockets  under  the  scalp.  A  torn  dura, 
like  a  torn  scalp,  may  be  partially  sutured.    Dirt  ground  into  the  tissues, 


304     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

whether  soft  tissues  or  bone,  must  be  cut  away  with  scissors  or  bone 
instruments. 

Loose  fragments  of  bone,  large  or  small,  free  or  impacted,  may  be 
retained  in  simple  fractures.  In  compound  fractures,  however,  they 
had  better  be  removed  unless  they  have  pericranial  attachments,  or 
unless  the  wound,  in  the  judgment  of  the  surgeon,  is  reasonably  clean. 
In  many  cases  they  can  be  retained  and  removed  later  if  necessary. 

In  fractures  of  the  base  operative  interference  is  seldom  called  for, 
and  then  it  is  only  on  the  ground  of  compression  from  hemorrhage  or 
edema,  or  because  of  infection.  Middle  meningeal  or  lateral  sinus 
hemorrhage  may  call  for  trephining  in  order  to  arrest  the  bleeding. 
General  oozing  or  cerebral  edema  may  lead  to  such  a  degree  of  compres- 
sion as  to  demand  relief  through  subtemporal  drainage  of  the  subdural 
space. 

The  only  justifiable  treatment  in  the  average  case  is  the  so-called 
expectant  treatment,  viz.,  absolute  quiet,  rest,  through  sedatives  if 
necessary,  ice-cap,  elevation  of  the  head  of  the  bed,  elimination  through 
cathartics,  normal  salt  solution,  etc.  Little  can  be  done  to  avoid  infec- 
tion through  the  open  connection  between  the  cranial  cavity  and  the 
air  sinuses  into  which  the  fracture  has  extended.  One  can,  however, 
at  least  avoid  the  added  dangers  of  meddlesome  irrigation,  spraying 
and  plugging  of  the  ear  and  nose.  In  the  case  of  the  ear  we  must  be 
content  with  gentle  cleansing  of  the  external  ear  and  canal  with  a 
swab  soaked  in  a  1  per  cent,  lysol  solution,  and  the  insertion  in  the  canal 
of  a  slender,  very  loosely  applied  strip  of  gauze  for  drainage.  A  sterile 
pad  should  be  applied  externally. 

If  the  case  does  not  die  during  the  first  forty-eight  hours  the  prog- 
nosis, so  far  as  recovery  is  concerned,  is  fairly  good,  but  one  should 
always  be  on  the  lookout  for  symptoms  calling  for  justifiable  inter- 
ference. Rest  in  bed  for  at  least  one  month,  and  avoidance  of  all  work 
or  mental  activity  for  at  least  six  months,  should  be  insisted  upon. 

Gunshot  Wounds  of  the  Skull. — Gunshot  wounds  of  the  skull,  like 
fractures  of  the  base,  are  in  a  class  by  themselves,  and  consequently 
are  separately  described.  Of  all  the  influences  governing  the  effects 
of  this  class  of  injury  the  chief  ones  are  the  physical  properties  of  the 
skull  contents  and  the  velocity  and  physical  properties  of  the  missile. 
The  semi-fluid  character  of  the  skull  contents  allows  the  active  force 
of  the  bullet  of  high  velocity  to  be  transmitted  in  all  directions,  in  other 
words  to  explode.  As  the  velocity  diminishes  the  explosive  effect  grows 
less  until  finally  the  results  may  become  no  more  nor  less  than  those  of 
a  punctured  wound,  or  a  mild  bending  fracture  from  a  spent  ball.  A 
soft  bullet,  such  as  is  used  in  the  ordinary  pistol  of  civil  life,  and  the 
partially  "  jacketed"  bullet  with  the  soft  nose,  such  as  is  used  in  hunting 
for  big  game,  flatten  out,  become  mushroomed,  when  they  strike  an 
object,  and  so  tear  frightful  holes  in  the  tissues.  Thus  with  a  low 
velocity  their  destructive  effects  on  the  skull  and  brain  may  be  just  as 
great  as  those  of  the  full-jacketed  bullets  of  higher  velocity.  Further- 
more the  soft  bullet  of  low  velocity  is  more  apt  to  become  fragmented 


WOUNDS  OF  THE  CRANIAL  BONES 


305 


and  lodge  in  the  skull  or  brain.  The  dum-dum  bullet  with  high  initial 
velodty  combines  the  action  of  the  deformed  missiles  with  that  of  the 
explosive  or  hydrodynamic  force. 


Fig.  75.— Gunshot  fracttire  of  skull,  posterior  view. 


FiG_  76 —Gunshot  fracture  of  skuU,  anterior  view. 


VOL.  I — 20 


306     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

The  injuries  of  the  dura  mater  correspond  somewhat  in  extent  with 
those  of  the  skull.  At  the  wound  of  entrance  the  inner  table  is  always 
more  extensively  shattered  than  the  external,  the  opposite  obtaining 
at  the  wound  of  exit. 

These  fractures  are  naturally  all  compound  with  more  or  less  com- 
minution and  displacement  of  fragments  or  loss  of  substance.  Many 
have  bursting  fissures  extending  into  the  base.  According  to  circum- 
stances the  fracture  may  be  a  perforating,  penetrating,  gutter  or 
simply  an  inbending  fracture.  Because  of  the  violence  of  the  intra- 
cranial injuries  leading  to  increased  tension,  these  cases  are  very  apt 
to  present  extrusion  of  the  brain  substance  at  the  points  of  fracture. 
Nerves  are  sometimes  implicated  without  the  skull  ca\dty  having  been 
penetrated.  Notable  examples  of  this  are  the  destruction  of  the  optic 
nerves  in  attempted  suicides. 

Diagnosis  and  Prognosis. — ^The  practical  points  in  the  diagnosis  and 
prognosis  concern  the  immediate  and  late  pathology  of  the  intracranial 
contents  and  cranial  nerves.  The  immediate  symptoms  due  to  the 
destruction  of  brain  tissue,  and  hemorrhage,  and  the  later  symptoms  of 
sepsis  and  brain  irritation  will  be  discussed  later  on. 

Skiagraphs  may  be  of  service  in  defining  more  or  less  of  the  bone 
lesions,  and  also  in  locating  the  bullet  or  its  fragments. 

Though  the  bullet  itself  is  to  be  looked  upon  as  free  from  infection, 
it  frequently  opens  up  a  track  through  septic  cavities,  or  it  may  carry 
with  it  pieces  of  hair,  cap,  etc.,  that  are  not  sterile. 

Nearly  half  of  the  cases  die  immediately,  and  a  further  percentage  die 
as  a  result  of  unavoidable  subsequent  complications. 

Treatment. — The  treatment  is  unsatisfactory  as  the  destruction  of 
the  brain  tissue  in  the  path  of  the  missile  or  within  the  reach  of  the 
"active  force"  of  the  bullet  with  high  velocity  cannot  be  repaired. 
Likewise  no  amount  of  skill  can  regularly  eliminate  infection  from  a 
fissured  base;  nor  can  foreign  bodies,  deeply  embedded,  be  extracted 
without  further  damage.  Even  an  early  leptomeningitis  at  the  base 
can  rarely  be  checked. 

Meddlesome  interference,  such  as  probing  and  irrigating  and  unneces- 
sary operating,  should  be  avoided.  Dry  shaving  and  painting  the 
site  of  the  scalp  wound  with  tincture  of  iodin  is  all  that  is  necessary  in 
some  cases;  in  others  operative  interference  is  indicated  for  the  removal 
of  pieces  of  bone  or  foreign  bodies  imbedded  in  the  surface  of  the  brain. 
If  drainage  should  be  indicated,  as  in  cases  where  foreign  bodies,  such 
as  bits  of  clothes,  hair,  etc.,  have  been  lodged  near  the  brain  surface, 
it  should  not  extend  deeper  than  the  subdural  space,  as  brain  drainage 
is  very  unsatisfactory,  and  may  be  very  harmful.  Complications,  such 
as  hemorrhage,  cerebral  edema,  infections,  etc.,  are  to  be  watched  for, 
and  met,  as  described  in  fracture  of  the  base.  A  bullet  which  has  lodged 
in  the  cranial  cavity  is  to  be  regarded  as  aseptic,  and  there  should  be  no 
attempt  at  its  removal  unless  it  is  in  a  readily  accessible  position,  or 
unless  it  is  causing  symptoms  of  brain  irritation. 


AFFECTIONS  OF  THE  CRANIAL  BONES  307 

Skull  Injuries  in  Infants  and  Young  Children. — ^Vault  fractures  or 
indentations  are  occasionally  seen  in  the  newborn  as  a  result  of  difficult 
labor  or  instrumental  delivery.  Even  fracture  of  the  base  has  been 
observed.  Indentations  are  also  seen  in  very  young  children  as  the 
result  of  falls.  To  admit  of  this  the  skull  bones  must  necessarily  be 
thin  and  very  elastic. 

These  cases  are  to  be  treated  on  the  same  general  principles  as  frac- 
tures in  adults,  except  that  the  indentation  should  be  allowed  a  week 
or  ten  days  to  undergo  spontaneous  reduction,  the  usual  occurrence. 
If  this  latter  does  not  take  place,  the  bone  should  be  forced  into  its 
proper  position  through  the  use  of  some  smooth  instrument,  like  a 
Kocher's  director,  inserted  through  a  small  opening  at  the  margin  of  the 
depression. 


Fig.  77. — Fracture  of  right  frontal  bone  in  a  newborn  infant,  fracture  extending  into 

orbit. 


AFFECTIONS  OF  THE  CRANIAL  BONES. 

Atrophy. — Atrophy  of  the  cranial  bones  is  of  interest  chiefly  from  the 
standpoint  of  diagnosis.  It  is  usually  a  local  process,  due  to  local  pres- 
sure, to  inflammatory  changes,  or  to  a  combination  of  local  pressure 
and  constitutional  disease.  It  may  occur  as  a  more  or  less  local  process 
in  the  form  of  the  so-called  eccentric  atrophy  of  old  people,  the  cause  of 
which  has  not  been  determined. 

Intracranial  pressure  under  normal  conditions  shows  its  effect  in  the 
depressions  for  the  Pacchionian  granulations,  and  the  grooves  for  the 
venous  sinuses  and  the  middle  meningeal  arteries.  Pathologically, 
pressure  atrophy  is  found  over  intracranial  tumors  situated  immedi- 
ately beneath  the  bone.  In  cases  of  prolonged  increased  intracranial 
tension  the  venous  stasis  may  lead  to  extensive  atrophy  through  dilata- 
tion of  the  veins  of  the  diploe,  or  it  may  show  itself  chiefly  at  the  site 


308    INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

of  the  emissary  vessels.  The  pressure  in  the  case  of  tumor  may  lead 
to  spontaneous  decompression  by  perforation  of  the  skull. 

Extracranial  pressure,  as  from  tumors,  notably  dermoids  and 
angiomas,  may  lead  to  atrophy  of  the  underlying  bone,  but  this  is  rare, 
because  the  soft  scalp  admits  of  easy  expansion  in  the  direction  of 
least  resistance.  Atrophy  has  followed  pressure  from  cephalhematoma. 

Senile  or  excentric  atrophy,  found  chiefly  in  old  men,  is  a  bilateral 
patchy  atrophy,  occurring  in  the  region  of  the  parietal  protuberances. 
Its  cause  is  unknown,  but  Konig  suggests  that  it  is  the  result  of  involu- 
tion changes.  The  atrophic  process  starts  in  the  diploe  and  extends 
outward,  leading  to  excavations  which  are  sometimes  mistaken  for 
fractures.    It  is  a  rare  affection. 


Fig.  78.^Craniotabes,  rachitis. 

Osteomyelitis,  especially  of  the  tuberculous  tyipe,  may  lead  to  a 
rarefaction  of  the  bone. 

The  atrophy  of  rickets  is  the  most  frequent  variety  met  with  in  the 
skull  bones.  These  spots  of  atrophy  are  found  chiefly  in  the  parieto- 
occipital region  and  are  knowni  as  craniotabes.  The  bone  at  these 
points  may  become  as  thin  as  paper,  or  even  disappear  altogether,  so 
that,  as  Konig  says,  the  occiput  may  feel  like  a  soft  abscess. 

Accompanying  the  absorption  of  the  bone  there  are  excessive  deposits 
of  soft  osteoid  tissue  in  the  frontal  and  parietal  regions,  which,  with  the 
flattening  of  the  occiput  from  pressure,  give  to  the  head  the  character- 
istic cuboidal  appearance.  The  fontanelles  are  larger  than  normal,  and 
may  remain  open  until  the  third  year.  The  edges  of  the  sutures  are 
usually  very  soft.  The  craniotabes  usually  disappears  before  the  end 
of  the  third  year  unless  complications  are  present.  The  deposits  of 
osteoid  tissue  in  the  frontal  and  parietal  regions  do  not  disappear,  but 
become  very  hard  as  recovery  takes  place. 


AFFECTIONS  OF  THE  CRANIAL  BONES 


309 


The  usual  constitutional  symptoms  and  other  skeletal  changes  are 
present.  ' 

Diagnosis. — ^The  diagnosis  is  usually  easy,  but  there  are  other  diseases 
presenting  as  part  of  their  pathology  areas  of  thin  bone  or  deformed 
cranial  bones,  large  fontanelles,  soft  suture  edges,  etc.  Among  these 
we  find  hydroce'phalii'S,  which  may  coexist  with  rachitis,  congenital 
fragilitas    ossium    or    osteogenesis    imperfecta,    chondrodystrophia  or 


Fig.  79. — Achondroplasic  skeleton. 

achondroplasia  (Jetal  rickets),  congenital  syphilis,  cretinism,  etc.  The 
associated  lesions  and  x-ray  findings  in  the  long  bones  will  help  to 
differentiate  most  of  these  conditions,  all  of  which  are  rare  except 
congenital  syphilis  and  hydrocephalus. 

In  achondroplasia  and  congenital  fragilitas  ossium  there  is  a  lack  of 
development  rather  than  an  atrophy  of  bone.  In  the  former  case  the 
pathology  is  confined  mostly  to  a  premature  union  of  the  epiphyses 


310     IXJURIES  AXD  DISEASES  OF  SKULL  AXD  ITS  COVERINGS 

of  the  long  bones    the  skull  usually  being  verv  little  aflfected      The 
intant  early  has  the  characteristic  appearance  of  a  dwarf.    The  head 


Fig.  80. — Achondroplasia. 


\ 


Fig.  81. — Osteopsathyrosis. " 

changes  in  congenital  fragilitas  ossiiim  are  often  verv  marked,  especially 
at  the  back,  where  the  bone  may  be  almost  entirely  wanting.    The 


AFFECTIONS  OF  THE  CRANIAL  BONES  311 

fragility  of  the  bones  throughout  the  body  leads  to  frequent  fractures, 
even  intra-uterine. 

Treatment. — The  treatment  is  entirely  along  general  lines.  Soft 
areas  in  the  skull  should  be  protected  from  pressure  by  ring  pads,  or 
inflated  ring  cushions. 

Carl  Beck,^  in  an  interesting  article  on  Osteopsath^Tosis,  refers  to 
Bossi's  clinical  and  experimental  work  in  connection  with  adrenalin  in 
the  treatment  of  osteomalacia.  He  says,  "  To  me  the  theory  of  Bossi 
seems  the  most  probable  that  the  suprarenal  capsules  have  an  influence 
upon  the  regulation  of  the  salt  deposits  in  bones,  and  that  the  absence 
of  the  particular  secretion  is  responsible  for  the  riot  of  the  cells  carrying 
on  the  absorption  of  lime  salts.  It  seems  to  be  borne  out  by  experiments 
as  well  as  by  the  good  results  obtained  by  Bossi  and  others,  and  also 
by  myself,  by  the  use  of  adrenalin." 

Bossi  found  in  his  experiments  on  sheep  that  removal  of  the  supra- 
renal capsules  was  followed  by  changes  almost  identical  clinically  and 
pathologically  with  osteomalacia,  and  thus  established  the  connection 
between  growth  of  bones  and  the  suprarenal  capsules. 

Beck  then  cites  the  case  of  a  young  girl  who  developed  a  softening  of 
most  of  the  bony  skeleton,  chiefly  of  the  long  bones,  with  a  great 
tendency  to  fractures;  and  very  little  disposition  to  healing.  "With 
the  injection  of  adrenalin  the  pathological  condition  gradually  shows 
clearly  an  increase  of  lime  salts  and  gradual  healing."  He  injected  ten 
to  twelve  drops  of  the  1  to  1000  solution  daily  for  twenty-five  days. 
Relief  from  pain  was  noticed  after  the  first  injection. 

Emil  Beck,  in  an  article  read  before  the  Chicago  Surgical  Society, 
cited  a  case  of  cystic  degeneration  of  bone  cured  by  the  use  of  adrenalin. 

A  number  of  the  cranial  hypertrophies,  separately  described  because 
differing  in  many  respects,  seem  to  possess  enough  fundamental 
similarities  to  warrant  the  conclusion  that  they  are  etiologically  related. 
Moreover,  one  form  may  be  associated  with  another  in  the  same 
individual.  The  chief  diseases  here  referred  to  are  acromegaly,  leontiasis 
ossea,  gigantism  and  osteitis  deformans. 

Acromegaly. — Acromegaly  is  a  systemic  disease  of  a  distinctly 
trophic  character,  invohdng  especially  the  osseous  system,  though  the 
soft  tissues  are  more  or  less  involved.  The  most  striking  feature  is 
general  hj^jertrophy  of  the  bony  skeleton.  The  bones  of  the  skull 
take  on  the  form  of  a  diffuse  hyperostosis,  those  of  the  face,  especially 
the  lower  jaw  and  the  supra-orbital  ridges,  becoming  very  heavy  and 
prominent,  giving  the  face  the  appearance  so  characteristic  of  the 
disease. 

The  onset  of  this  condition  occurs  usually  in  late  youth  or  early  adult 
life,  and  tends  to  a  fatal  issue  in  from  ten  to  thirty  years.  Most  cases 
are  associated  with  some  pathology  of  the  h\^ophysis  cerebri,  though 
cases  of  acromegaly  and  allied  conditions  have  been  reported  in  which 
the  autopsy  showed  no  lesions  of  the  hj^ophysis;  and,  on  the  other 

iSurg.,  Gynec.  and  Obstet.,  1910. 


312    INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 


Fig.  82. — Acromegaly. 


Fig.  83. — Leontiasis:     skull  of  a  Chinese  woman. 


AFFECTIONS  OF  THE  CRANIAL  BONES  313 

hand,  lesions  of  the  hj'pophysis  have  been  found  in  cases  with  no  sign 
of  trophic  changes  in  the  bony  skeleton. 

Treatment. — Operation  may  possibly  prove  of  benefit  in  those 
cases  where  the  symptoms  and  .T-ray  findings  point  to  disease  of  the 
hypophysis. 

Gigantism. — Meige^  states  that:  "When  the  disease  commences  in 
youth  we  get  a  case  of  gigantism;  when  in  adult  life  acromegaly;  if 
commencing  in  youth  and  continuing  into  adult  life  we  get  a  combin- 
ation of  the  two.  Acromegaly  never  precedes  gigantism.  Acromegaly 
sets  in  during  the  course  of  about  one-half  of  the  cases  of  gigantism." 
Woods  Hutchinson-  states  that  we  are  "  justified  at  least  in  the  tentative 
conclusion  that  acromegaly  and  gigantism  are  simply  different  expres- 
sions of  one  and  the  same  morbid  condition." 

The  average  duration  of  life  is  seldom  over  twenty  years. 

Leontiasis  Ossea. — ^Leontiasis  ossea  is  a  chronic  disease  of  unknown 
origin  leading  to  marked  diffuse  thickening  and  sclerosis  of  the  bones  of 
the  face  and  cranium.  Either  or  both  sets  of  bones  may  be  involved. 
Bassoe^  states  that  "Baumgarten's  view  that  the  disorder  is  trophic 
and  developmental  is  probably  the  best  at  present."  It  usually  starts 
in  childhood,  beginning  as  a  rule  in  one  of  the  bones  of  the  face.  "Of 
the  cranial  bones  the  anterior  part  of  the  frontal  is  usually  most 
affected."     (Bassoe). 

The  massive  thickening  of  these  bones  leads  to  a  gradual  diminution 
in  size  of  the  cranial  chamber  and  more  or  less  obliteration  of  the 
foramina  and  accessory  ca\dties  of  the  skull.  These  changes  eventually 
give  rise  to  the  various  symptoms  of  cerebral  compression  and  cranial 
nerve  impingement.  The  orbit  being  more  or  less  obliterated,  exoph- 
thalmos is  one  of  the  results. 

Diagnosis. — Though  some  authors  consider  Osteitw  deformans  of 
Paget  as  identical  with  this  disease,  still  leontiasis  ossea  is  described 
as  a  diffuse  hypertrophy  limited  to  the  bones  of  the  face  and  cranium 
while  the  osteitis  deformans  involves  the  spine  and  lower  extremities  as 
well  as  the  cranium,  von  Bruns  states  that  while  osteitis  deformans 
fibrosa  may  involve  the  skull  alone  it  must  be  admitted  that  the  skull 
affection  may  represent  the  beginning  of  a  general  disease  of  the 
skeleton.  Osteitis  deformans  furthermore  does  not  involve  the  bones 
of  the  face.  Acromegaly  always  begins  in  the  epiphyses  of  the  long 
bones  of  the  extremities.  Sarcoma  of  the  maxillary  bones  may  be 
mistaken  for  the  early  hyperostosis  of  leontiasis  ossea,  or  it  may  be 
associated  with  the  latter. 

Treatment. — There  is  no  curative  treatment  of  this  malady,  though 
operations  have  been  performed  with  the  idea  of  relieving  pain  due  to 
nerve  compression.  The  duration  of  the  disease  may  vary  from  ten  to 
thirty  years. 

^Arch.  gen.  de  med.,  October,  1902. 

ii  New  York  Med.  Jour.,  March  12,  1898. 

'  Jour.  Nerv.  and  Ment.  Dis. 


314         INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 


Fig.  84. — Case  of  pre-adolescent  hyperpituitarism,  with  giant  overgrowth.  Enlarged 
sella  turcica.  Weight,  275  pounds;  height,  8  feet,  3  inches.  Note  the  narrow  chest, 
enlarged  joints,  hypertrichosis,  and  large  size  of   hands.      (From  Cushing's  Pituitary 

Body.) 


ACUTE  INFECTIONS  OF  THE  CRANIAL  BONES  315 

Osteitis  Deformans. — Osteitis  deformans,  also  known  as  Paget's 
disease  of  bone,  is  a  very  rare  disease,  leading  to  irregular  but  sym- 
metrical enlargement  and  deformity  of  more  or  less  of  the  bony  skeleton. 
It  occurs  chiefly  in  middle  life  and  is  found  most  frequently  in  men. 
The  cause  of  this  condition  is  not  known.  While  the  long  bones  of  the 
extremities  become  thickened  and  elongated  they  also  become  bent  in 
various  directions.  These  changes,  combined  with  osteophytic  deposits 
here  and  there  and  curvature  of  the  spine,  lead,  at  times,  to  very 
grotesque  deformities,  and  a  decided  shortening  of  stature.  The  skull 
changes  usually  affect  only  the  cranial  bones  in  the  form  of  an  excentric 
hypertrophy.  For  this  reason  there  are  seldom  present  the  symptoms  of 
intracranial  compression. 


Fia.  85. — Osteitis  deformans  (Paget's  disease)  in  a  patient,  aged  seventy-two  years. 
Duration,  twelve  years.     Orthopaedic  Hospital.     (Ashhurst.) 

ACUTE  INFECTIONS  OF  THE  CRANIAL  BONES. 

Acute  Pyogenic  Osteomyelitis  or  Periostitis. — Acute  pyogenic  osteo- 
myelitis or  periostitis  of  the  cranial  bones  is  exceedingly  rare  as  a 
hematogenous  infection.  While  it  may  take  place  in  this  way  after 
trauma,  or  even  without  the  latter,  it  usually  occurs  in  connection  with 


316     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS   COVERINGS 

an  open  scalp  wound,  or  by  direct  extension  from  one  of  the  accessory 
sinuses. 

Acute  infection  under  tension  in  the  diploe,  regardless  of  how  it 
reached  the  area,  gives  rise  to  both  the  constitutional  symptoms  and 
the  local  signs  of  acute  osteomyelitis,  viz.,  usually  a  chill,  always  fever, 
and  always  marked  pain  and  local  sensitiveness.  Infective  thrombo- 
phlebitis may  spread  extensively  through  the  diploetic  veins  or  the 
emissary  vessels  and  reach  one  of  the  large  venous  sinuses,  causing 
thrombosis,  or  the  pus  may  rupture  into  the  subpericranial  area,  strip- 
ping up  the  periosteum,  or  it  may  perforate  the  bone  internally,  leading 
to  an  extradural  abscess  with  cerebral  compression,  or  it  may  even  lead 
to  a  meningitis,  a  local  brain  abscess,  or  a  diffuse  meningo-encephalitis, 
or  it  may  serve  as  the  focus  of  a  pyemia.  As  in  the  long  bones,  so  here 
in  the  skull,  the  early  stages  of  the  infection  may  be  unaccompanied 
by  marked  swelling  of  the  soft  parts.  Later,  as  the  tension  is  relieved 
by  perforation  of  the  bone,  there  may  be  considerable  swelling  of  the 
scalp.  Necrosis  may  be  limited  or  extensive.  The  peculiar  thing  about 
the  cranial  bone  necrosis  is  that  no  involucrum  is  formed  as  in  the  long 
bones.    Only  occasionally  is  a  slight  one  formed. 

Diagnosis  and  Prognosis.- — While  the  diagnosis  is  usually  easy  the 
prognosis  is  always  serious  because  of  the  possibilities  of  intracranial 
infection. 

Treatment. — The  treatment  indicated  is  drainage  of  the  infected  area 
within  the  first  twenty-four  or  thirty-six  hours.  As  in  the  case  of  the 
long  bones,  release  of  tension  by  removing  one  or  more  buttons  of  the 
outer  table  is  all  that  is  usually  necessary.  It  is  of  the  greatest  prac- 
tical importance  in  these  cases  to  make  early  extensive  incisions  through 
the  periosteum  down  to  the  bone  because  this  causes  the  lymph  stream 
to  carry  the  infections  away  from  the  body.  If  there  is  any  question 
about  extradural  infection  the  trephine  opening  should  extent  through 
the  entire  thickness  of  the  skull.  Later,  when  necrosis  has  occurred 
free  drainage  is  still  indicated  until  the  necrotic  bone  is  well  outlined, 
when  it  should  be  removed,  as  waiting  until  it  is  loose  would  prolong 
the  possibilities  of  intracranial  inflammations. 

Syphilis. — Syphihs  of  the  cranial  bones  or  their  periosteal  coverings 
is  usually  found  as  tertiary  lesions  of  acquired  syphilis,  though  it  some- 
times occurs  as  a  hereditary  manifestation  in  children.  It  usually 
starts  in  the  pericranium,  but  may  involve  the  diploe  first.  Both 
become  involved  more  or  less  in  either  case.  The  brow  and  the  top  of 
the  head  are  the  favorite  seats,  the  base  being  rarely  affected.  The 
spirochetes  are  abundant  in  the  gummata  of  infants.  Trauma  is  often 
the  cause  of  the  localization. 

Symptoms.— The  subjective  symptoms  may  be  few  and  mild. 
Though  tenderness  is  present,  pain  is  usually  not  a  prominent  feature 
unless  the  disease  involves  the  dura,  primarily,  or  secondarily  as  a 
pachymeningitis  externa.  When  pain  is  present,  as  in  some  of  the 
cases  developing  acutely,  it  is  usually  worse  at  night,  as  in  most  chronic 
bone  inflammations. 


ACUTE  INFECTIONS  OF  THE  CRANIAL  BONES 


317 


The  gummata  appear  as  solitary  or  multiple  lesions,  tender,  slightly 
elevated  and  firmly  fixed  to  the  bone.  Chronic  from  the  beginning, 
they  tend  to  gradually  increase  in  size  and  coalesce,  often  forming 
irregular  serpiginous  patches  of  bone  destruction.  The  rarefaction 
and  absorption  of  the  bone,  most  marked  along  the  Haversian  canals, 
is  accompanied  by  an  overproduction  and  sclerosis  of  bone  at  the 
periphery  of  the  lesion,  forming  at  times  tophi  and  nodules.  The  des- 
truction, however,  exceeds  the  new  bone  formation.  The  caseation 
and  softening  may  extend  to  the  dura,  which  usually  acts  as  an  effec- 
tive barrier,  or  it  may  extend  outward  and  lead  to  scalp  ulceration  and 
sinus  formation  with  their  characteristic  earmarks.  The  dura  may 
become  thickened  and  contracted.    The  entire  process  may  be  limited 


**::*# 

'^^/ 


Fig.  86. — Syphilitic  caries  of  cranium. 


to  a  small  area  of  local  caries  or  it  may  result  in  extensive  necrosis, 
usually  in  such  form  as  to  give  the  skull  a  worm-eaten  appearance. 
Pulsation  of  the  swelling  may  be  present  after  perforation  of  both 
tables.  The  gravity  of  the  case  is  usually  altered  by  the  mixed  infection 
which  often  occurs  in  connection  with  the  marked  softening. 

Diagnosis.^ — The  diagnosis  ordinarily  should  not  be  difficult.  One 
or  more  chronic,  slightly  tender,  rather  painless  swellings  on  the  vault 
of  the  skull,  with  a  history  of  syphilis  some  years  before,  and  with  a 
positive  Wassermann  reaction,  would  leave  practically  no  question 
about  the  diagnosis.  The  vast  majority  of  cases  of  osteomyelitis  of  the 
skull,  especially  on  the  forehead  and  the  top  of  the  head,  not  due  to 
trauma,  are  syphilitic. 


318     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

The  diagnosis  is  most  difficult  in  the  early  stages  when  there  is  no 
history  of  syphilis.  In  this  case  the  solitary  lesion  might  be  mistaken 
for  sarcoma,  but  the  multiple  lesions  never.  Tuberculous  osteomyelitis 
might  have  to  be  differentiated.  This,  however,  is  usually  found  in  . 
children,  and,  in  almost  any  event,  has  usually  a  primary  focus  of  tuber- 
culosis in  the  lungs  or  glands,  or  some  other  portion  of  the  body.  Not 
only  that,  but  it  is  more  apt  to  be  found  associated  with  a  tubercu- 
lous sinusitis,  especially  of  the  mastoid.  The  tuberculin  test  should 
be  positive.  Other  granulomata,  though  exceedingly  rare,  must  be 
thought  of. 

In  syphilis  there  can  usually  be  found  associated  lesions,  character- 
istic of  the  disease,  hi  other  parts  of  the  body.  Furthermore  the  posi- 
tive Wassermann  and  the  response  to  rigid  antisyphilitic  treatment 
clinches  the  diagnosis. 

Treatment. — The  treatment  consists  in  energetic  antiluetic  treatment, 
which  is  often  all  that  is  necessary.  Free  drainage  is  indicated  in  all 
suppurating  cases.  Gummata  resisting  treatment  should  be  opened, 
curetted  and  packed  or  excised.  Dead  bone  should  be  removed  with  a 
chisel  or  curette,  care  being  used  to  avoid  unnecessary  denudation  of 
the  living  bone.  Intracranial  tension  from  extradural  gummata  or 
exudates  calls  for  relief  through  trephining  if  there  is  no  prompt 
response  to  medication.  No  delay  is  admissible  if  the  pressure  is  great. 
In  cases  of  pach^aneningitis  externa  that  have  resisted  treatment  care- 
ful curettement  is  indicated,  providing  cerebral  symptoms  are  present. 
Defects  of  soft  parts  or  of  the  skull  may  be  corrected  through  plastic 
surgery,  though  quite  a  number  of  cases  are  on  record  showing  a 
considerable  reproduction  of  the  bone  in  these  sj'philitic  cases,  due 
probably  to  the  activity  of  the  dura. 

Tuberculosis.— Tuberculosis  of  the  cranial  bones,  while  more  com- 
mon than  it  was  formerly  thought  to  be,  is  nevertheless  a  rather  rare 
condition,  limited  almost  exclusively  to  childhood.  It  is  usually  only 
a  part  of  a  more  or  less  generalized  tuberculosis.  It  occurs  as  circum- 
scribed or  diffuse  lesions  starting  generally  in  the  diploe.  The  circum- 
scribed lesions  usually  perforate  the  bone  in  both  directions,  though 
occasionally  only  one  or  the  other  of  the  two  tables  may  be  involved. 
A  cold  abscess  is  the  usual  result.  The  diffuse  lesions,  the  so-called 
infiltrating  t;^Tpes,  spread  along  the  diploe,  perforating  here  and  there 
toward  the  dura  or  toward  the  scalp,  resulting  in  more  or  less  necrosis 
of  the  bone  and  tortuous  sinuses  in  the  soft  parts.  The  granulomatous 
mass  on  the  inner  surface  of  the  skull  may  push  the  dura  away  from  the 
bone  and  set  up  a  pachymeningitis.  A  leptomeningitis  from  direct 
invasion  is  rare,  though  not  uncommon  as  a  hematogenous  infection. 
These  tuberculous  lesions  tend  to  bone  destruction  exclusively,  rather 
than  to  a  combination  of  overproduction  and  absorption  as  occurs  in 
syphilis.  Tuberculosis  of  the  temporal  bone  is  in  a  class  by  itself, 
being  usually  secondary  to  tuberculosis  of  the  mastoid.  It  will  be 
described  in  a  subsequent  chapter. 


ACUTE  INFECTIONS  OF  THE  CRANIAL  BONES 


319 


Symptoms. — ^The  symptoms  of  tuberculosis  of  the  cranial  bones  are 
largely  objective.  Slight  pain  in  the  head  and  local  tenderness  followed 
by  a  soft,  torpid,  fluctuating  swelling  not  due  to  trauma,  with  later 
discoloration  and  perforation  of  the  overlying  skin  and  sinus  formation, 
constitute  the  usual  sequence  of  symptoms.  The  afternoon  tempera- 
ture is  always  in  evidence.  The  mouths  of  the  sinuses  have  the  char- 
acteristic appearance  of  tuberculous  sinuses.  At  the  bottom  of  the 
tract  one  can  frequently  find,  in  the  circumscribed  cases,  a  small  circular 
sequestrum  which  can  usually  be  easily  lifted  out,  contrary  to  the  case 
in  syphilitic  necrosis.  The  soft  swelling  may  pulsate  with  the  brain  in 
some  cases  of  perforation  of  the  skull. 


Fig.  87. — Perforating  tuberculosis  of  the  sivull. 


Diagnosis. — In  the  differential  diagnosis  syphilis  can  ordinarily  be 
excluded  by  the  absence  of  other  lesions  characteristic  of  syphilis,  by 
the  negative  Wassermann  test,  and  by  the  fact  that  syphilis  of  bone  is 
usually  found  in  adult  life  rather  than  during  childhood.  In  the  tuber- 
culous cases  one  can  usually  obtain  a  positive  tuberculin  reaction. 
Glanders  and  actinomycosis  are  exceedingly  rare  in  the  cranial  bones 
and,  when  they  do  occur,  it  is  only  as  a  secondary  manifestation  of  the 
infection  in  some  other  part.  The  specific  microorganism  can  be  demon- 
strated in  each  case. 

Treatment.— The  treatment  of  tuberculosis  of  the  skull  consists  in  the 
operative  removal  of  the  local  lesion  if  possible,  unless  contra-indicated 
by  the  gravity  of  the  associated  lesions.  Operation  is  especially 
indicated  where  meningeal  or  cerebral  symptoms  indicate  a  pachy- 
meningitis with  pressure.  Bone  defects,  as  in  syphilis,  are  sometimes 
filled  in  spontaneously.  When  operation  is  out  of  the  question,  the 
case  must  be  handled  as  any  other  case  of  so-called  surgical  tuber- 
culosis.   The  unruptured  cold  abscess  should  be  aspirated  and  care- 


320     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

fully  injected  with  formalin  and  glycerine  or  iodoform  emulsion;  but 
if  mixed  infection  has  already  occurred  free  drainage  is  indicated. 

In  any  event  the  case  always  calls  for  the  modern  general  dietetic 
and  hygienic  care  of  tuberculous  individuals,  including  the  use  of  the 
tuberculin. 


Fig.  88. — Exostosis  of  the  skull. 


TUMORS  OF  THE  CRANIAL  BONES. 

Osteoma. — Osteoma  is  a  benign  tumor  occurring  as  an  exostosis 
chiefly  on  the  outer  surface  of  the  cranial  bones,  though  it  is  also  found 
on  the  inner  surface  or  in  one  of  the  accessory  sinuses.  It  generally 
appears  at  puberty.  Enostosis,  arising  from  the  diploe,  is  seldom,  if 
ever,  seen  in  the  cranial  bones.  The  exostoses  are  most  frequently  seen 
on  the  frontal  or  parietal  bones,  usually  as  a  solitary  gro^\i;h  and  gener- 
ally of  the  compact  type.  External  and  internal  exostoses  have  been 
seen  at  the  same  site.  As  most  of  the  cranial  bones  are  laid  down  in 
membrane  the  fibrous  osteoma  is  the  prevailing  type,  though  chondral 
osteoma  has  been  met  with  in  the  ethmoid  and  sphenoid.  Osteophytes, 
probably  of  inflammatory  origin,  are  sometimes  found  on  the  .inner 
surface  of  the  cranial  bones,  especially  in  pregnant  women  and  tuber- 
culous cases. 

According  to  their  structure  osteomata  are  spoken  of  as  hard, 
eburnated  or  spongy.  In  size  they  vary  greatly.  While  most  of  those 
on  the  cranium  are  sessile,  the  pedunculated  are  sometimes  found. 


TUMORS  OF  THE  CRANIAL  BONES 


321 


Diagnosis. — The  diagnosis  of  the  external  osteomata  of  the  cranial 
vault  is  usually  easy  as  they  are  slow-growing  hard  tumors  firmly 
attached  to  the  bone,  with  no  invasion  of  the  soft  parts.  They  are 
entirely  symptomless.     Sarcoma,   especially  ossifying   sarcoma  and 


Fig.  89.— Osteoma  of  skull. 


Fig    90. — Same  as  Fig.  89,  seen  from  below. 


gumma,  sometimes  call  for  exclusion.  Konig  mentions  local  atrophy 
of  the  skull,  with  bulging  due  to  intracranial  pressure,  as  of  some 
differential  diagnostic  importance. 

The  diagnosis  of  the  internal  exostoses  is  a  more  difficult  matter.    As 
they  are  of  very  slow  growth  the  brain  may  show  no  signs  of  irritation 

VOL.  I 21 


322     INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

or  compression  from  a  moderate-sized  tumor,  especially  over  a  silent 
area.  Where  symptoms  are  present  they  are  usually  those  of  irritation 
or  paralysis  of  the  cerebral  cortex  or  cranial  nerves.  Even  then  exos- 
tosis will  hardly  be  thought  of  unless  revealed  by  an  .r-ray  examination, 
or  unless  an  external  osteoma  is  present. 

The  signs  of  osteoma  in  the  accessory  sinuses  depend  upon  the  special 
sinus  involved.  As  it  grows  it  causes  an  expansion  of  the  sinus  walls  in 
the  direction  of  least  resistance  with  a  displacement  of  the  adjoining 
soft  parts.  There  is  also  a  tendency  to  sinus  infection  due  to  inter- 
ference with  drainage,  and  sometimes  cerebral  or  meningeal  infection, 
leading  to  the  diagnosis  of  ordinary  sinusitis.  Thus  a  bulging  over  the 
region  of  the  frontal  sinus  with  displacement  of  the  eye  downward 
and  outward,  combined  with  attacks  of  sinusitis,  is  characteristic  of  a 
frontal  sinus  osteoma.  In  the  sphenoidal  sinus  the  optic  nerves  may  be 
compressed  or  the  growth  may  reach  into  the  nasal  cavity. 

Treatment. — The  treatment  of  exostoses  depends  upon  the  location 
and  the  form  of  the  tumors,  and  the  presence  or  absence  of  symptoms 
due  to  the  growth.  Thus  a  pedunculated  or  a  very  unsightly  tumor 
should  be  removed;  also  one  causing  cerebral  or  cranial  nerve  symp- 
toms or  displacements  of  important  structures,  such  as  the  eye.  Those 
leading  to  sinus  infection  should  also  be  removed.  The  internal  and 
sinus  cases  will  often  call  for  exploration.  If  operation  is  attempted 
thorough  removal  should  be  the  rule  in  order  to  avoid  recurrence.  The 
sinus  cases  naturally  have  a  decided  mortality  rate  due  to  infection. 

Camrnama. — Borchardt^  cites  an  interesting  case  of  cavernoma 
communicating  with  the  superior  longitudinal  sinus,  which  presented 
itself  as  a  pulsating  tumor  near  the  junction  of  the  sagittal  and  lamb- 
doidal  sutures.  The  entire  venous  system  of  the  skull  was  dilated, 
though  the  arteries  were  found  to  be  normal  at  the  subsequent  post- 
mortem. Intracranial  pressure  was  evidenced  by  the  bilateral  choked 
disks.  He  regarded  the  case  as  a  progressive  phlebectasia  pericranii  of 
congenital  origin. 

Schone  has  described  8  cases  of  central  cavernoma,  and  Blecher  5 
cases  of  cholesteatoma  of  the  cranial  bones,     (v.  Bruns.) 

Echinococcus  Cysts. — Echinococcus  cysts  of  the  cranial  bones  are 
exceedingly  rare.  They  occur  in  the  diploe,  and  those  reported  have 
been  of  the  unilocular  type,  though  most  cases  in  the  long  bones  are  of 
the  multilocular  variety.  Atrophy  of  the  adjacent  bone  occurs.  The 
complement-fixation  test  in  the  diagnosis  of  echinococcus  lesions  is  very 
satisfactory. 

Treatment. — The  treatment  of  the  unilocular  cases  consists  in  removal 
of  the  lining  membrane  and  drainage. 

Sarcoma. — Sarcoma  of  the  cranial  bones  is  rare  in  comparison 
with  sarcoma  of  the  extremities.  It  may  be  found  at  any  site  at  any 
age.  It  is  not  infrequent  in  children,  and  has  been  found  in  the  newborn. 
It  may  be  primary  or  metastatic,  and,  though  usually  solitary,  it  may 
be  multiple. 

1  Zeutralbl.  f.  Chir.,  1913,  xxviii,  33. 


TUMORS  OF  THE  CRANIAL  BONES 


323 


Histology. — The  histology  of  sarcoma  of  the  cranial  bones  is  the  same 
as  in  other  regions  of  the  bony  skeleton.  It  may  start  primarily  in  the 
pericranium,  the  dura  or  the  diploe.  Any  one  of  the  various  cell  types 
may  predominate,  the  round,  the  spindle,  or  the  giant  cell,  though  the 
spindle  cell  seems  to  be  most  frequently  found.  The  giant  cell  belongs 
to  the  myelogenous  sarcoma.  Often  there  are  mixed-cell  t^^)es.  Endo- 
thelioma may  arise  from  the  vessels  in  the  bone,  gi^Tng  rise  to  angio- 
sarcoma. 

Symptoms. — The  symptoms  naturally  depend  upon  the  location  of 
the  tumor,  whether  encroaching  upon  the  cranial  cavity  or  not,  upon 
the  matter  of  invasion  of  the  brain  or  involvement  of  the  cranial  nerves 
or  accessory  sinuses,  etc.    As  a  matter  of  fact  the  dura  seems  to  act  as 


Fig. 


91. — Osteosarcoma  of  the  temporal  region. 

thjToid. 


Metastatic  tumor  in  the  arm  and 


a  barrier  against  invasion  and  so  the  sarcoma  tends  outward,  no  matter 
where  it  starts.  In  the  cases  starting  on  the  inner  surface  the  symptoms 
may  be  the  general  sjTiiptoms  of  brain  tumor,  plus,  in  many  cases,  the 
focal  symptoms  due  to  pressure  on  or  invasion  of  some  special  point 
on  the  cortex  of  the  brain.  When  perforation  of  the  skull  eventually 
occurs  the  cerebral  pressure  sjTiiptoms  are  relieved  and  the  tumor 
becomes  manifest  under  the  scalp.  Before  long  the  scalp  is  invaded,  its 
subcutaneous  veins  greatly  enlarged  and  ulceration  results  in  the  usual 
bleeding  fungus  of  sarcoma. 

In  myelogenous  sarcoma  arising  in  the  diploe  the  periosteal  irritation 
sometimes  leads  to  the  formation  of  a  bony  capsule  on  the  outer  side, 
resembling  a  separation  of  the  tables,  or,  in  the  early  stages,  an  osteoma. 


324    INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

In  this  variety  and  in  those  starting  on  the  surface  of  the  skull  there  are 
usually  no  brain  symptoms,  except  possibly  headache,  and  the  tumor 
presents  itself  early  as  an  external  swelling  with  sometimes  more  or  less 
pain  and  tenderness. 

Diagnosis. — The  diagnosis  of  sarcoma  of  the  cranial  bones,  like  most 
deep  tumors  in  other  portions  of  the  body,  is  seldom  made  in  the  earliest 
stages  when  operation  has  the  most  to  offer.  Too  often  it  is  the  visible 
or  palpable  tumor  that  is  the  first  recognized  sign  of  sarcoma  of  the 


Fig.  92. — Fungating  osteosarcoma  of  cranium. 


skull.  At  first  this  tumor  is  a  flat,  rounded  swelling  attached  immov- 
ably to  the  bone.  Though  it  may  be  hard  at  first,  it  frequently  becomes 
softer  in  the  later  stages,  and,  as  it  grows  more  rapidly  in  the  softer 
tissues  than  in  the  bone,  it  may  be  somewhat  constricted  at  the  base. 
The  galea  for  a  time  may  act  as  a  barrier  to  malignant  invasion,  but 
soon  the  fixation  of  the  skin,  with  its  enlarged  veins,  becomes  marked. 
Given  such  a  tumor  in  the  early  stages,  it  is  necessary  to  differ- 
entiate sarcoma,  primary  or  secondary,  secondary  carcinoma,  gumma, 
tuberculosis   and    actinomycosis.     The   rare    myeloma,   cidoroma   and 


TUMORS  OF  THE  CRANIAL  BONES  325 

echinococcus  cysts,  as  well  as  the  more  common  simple  osteoma,  must 
also  be  considered. 

A  general  physical  examination  will  help  to  determine  the  presence 
or  absence  of  similar  or  coincident  lesions  in  other  portions  of  the  body, 
and  thus  aid  in  the  differentiation  of  syphilis  and  tuberculosis,  metas- 
tatic sarcoma  and  secondary  carcinoma.  An  accurate,  orderly  clinical 
history,  combined  with  the  usual  Wassermann  and  tuberculin  tests,  are 
absolutely  necessary.  A  skiagraph  may  be  of  distinct  service.  In  case 
syphilis  cannot  be  excluded  by  these  means  a  vigorous  antisyphilitic 
treatment  for  three  weeks  should  be  tried.  Tuberculosis  is  more  apt  to 
present  itself  as  a  soft  fluctuating  mass,  a  cold  abscess  from  the  begin- 
ning; while  actinomycosis  is  a  distinctly  inflammatory  tumor,  and  is 
practically  always  present  in  some  other  part  of  the  body  primarily. 
After  the  tumor  is  once  open  the  finding  of  the  ray  fungus  settles  the 
diagnosis.  Myeloma  shows  itself  as  multiple  myelogenous  tumors, 
confined  entirely  to  the  bony  skeleton,  with  the  Bence-Jones  body  in 
the  urine.  Myelogenous  sarcoma  in  the  early  stages  with  its  outer  wall 
of  new  periosteal  bone,  and  ossifying  sarcoma,  may  be  mistaken  for  a 
time  for  simple  osteoma  (exostosis).  The  rapid  growth  of  sarcoma, 
however,  soon  rules  out  osteoma.  Sarcoma  of  the  dura  must  present 
symptoms  more  like  a  brain  tumor,  and  hence  is  not  usually  considered 
in  the  above  diagnosis  until  it  begins  to  perforate  the  skull,  or  until  a 
skiagraph  offers  the  suggestion. 

Treatment. — The  treatment  of  sarcoma,  here  as  elsewhere,  consists 
in  wide  excision  unless  the  case  is  considered  inoperable  because  of 
metastasis  or  too  extensive  local  invasion.  Excision  with  the  actual 
cautery  has  distinct  advantages.  From  the  standpoint  of  the  cell  type 
the  myelogenous  variety  should  offer  the  best  prognosis,  but,  as  a 
matter  of  fact,  the  external  or  pericranial  tumor  can  be  recognized 
earliest  of  all,  and  hence  should  offer  a  prognosis  which  is  less  serious 
than  that  of  the  deeper  sarcomas.    They  are  all  bad. 

Myeloma  (Multiple  Myelema). — Myeloma  is  a  systemic  disease 
characterized  by  the  formation  of  multiple  tumors  confined  entirely  to 
the  osseous  system,  the  bones  of  the  trunk  and  skull  rather  than  the 
long  bones  being  chiefly  involved.  Starting  in  the  marrow  it  leads  to  a 
softening  and  absorption  of  the  bone.  Simultaneous  development  of 
multiple  foci,  rather  than  metastasis,  is  the  rule.  It  has  been  found 
more  often  in  males  over  forty  years  of  age.  The  cause  of  the  disease 
is  unknown.  The  urine  in  these  cases  contains  a  heterogenous  albumose 
known  as  the  Bence-Jones  body.  This  body  has  been  found  in  the  urine 
prior  to  the  recognition  of  the  tumors.  The  prognosis  is  absolutely 
hopeless. 

Chloroma. — Chloroma  is  a  very  rare  form  of  tumor  which  derives 
its  name  from  its  green  color.  It  seems  to  have  some  connection  with 
myelogenous  leukemia  and  spreads  by  metastasis  like  a  sarcoma. 
Simmonds  and  Romer^  conclude  that  "Chloroma  is  only  a  biological 

1  Deutsch.  med.  Wchnschr.,  1914,  xl,  260. 


326    INJURIES  AND  DISEASES  OF  SKULL  AND  ITS  COVERINGS 

subvariety  of  leukemia  with  a  special  tendency  to  malignant  prolifer- 
ation." ileid^  states  that  "they  originate  in  the  periostemn,  generally 
of  the  skull  bones,  and  show  unbounded  proliferation  into  the  soft  parts. 
They  are  generally  accompanied  by  changes  in  the  blood  picture."  He 
cites  a  case,  however,  which  did  not  originate  in  the  periosteum  and 
which  was  not  accompanied  by  blood  changes.  The  blood  changes  are 
those  of  myeloblastic  leukemia.  Dock-  calls  attention  to  the  fact  that, 
notwithstanding  their  usual  origin  in  the  periosteum,  they  show  none 
of  the  elements  ordinarily  found  in  periosteal  tumors — no  spindle  or 
giant  cells,  and  no  tendency  to  bone  formation.  They  are  associated 
with  the  myeloblastic  type  of  leukocyte.  He  calls  it  an  aberrant  form 
of  myelomatosis.  Authors  disagree  as  to  whether  the  disease  is  to  be 
classed  among  the  leukemias  or  the  sarcomata.  The  cause  of  this 
disease  is  unknowii.  It  occurs  chiefly  in  the  bones  of  the  skull,  the  spine 
and  in  the  humerus.  The  tumors  on  the  skull  are  said  to  form  "  flat, 
plate-like  masses,  often  extending  over  large  areas."  (Hektoen- 
Riesmann.^) 

1  Beitr.  z.  klin.  Chir.,  1915,  xcv,  47. 

2.\iii.  Jour.  Med.  Sc,  1893,  c\'i,  152. 

'  An  American  Text -book  of  Pathology,  p.  205. 


DIAGNOSIS  AND  TREATMENT  OF  TUMOES, 

INFLAMMATIONS  AND  ABSCESSES 

OF  THE  BEAIN. 

By  ALLEN  B.  KANAVEL,  M.D., 
TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN. 

Diagnosis  in  Brain  Tumors. 

There  is  no  more  fascinating  field  in  surgery  than  that  of  diagnosis 
in  brain  tumors — fascinating  because  it  calls  for  the  highest  degree  of 
reasoning  power  based  upon  an  intimate  knowledge  of  intricate 
anatomical  structures  and  for  an  intensive  study  of  the  symptoms  and 
signs  to  be  elicited  in  a  given  case.  Many  are  the  disappointments  of 
the  most  careful  observer  and  yet,  on  the  other  hand,  brilliant  success 
does  at  times  reward  the  student.  Much  of  the  pessimism  of  the 
profession  regarding  results  in  brain  tumor  cases  is  justified,  but 
unfortunately  this  pessimism  has  been  unduly  magnified  by  careless 
diagnosis  on  the  part  of  the  internist  and  by  hasty,  injudicious  oper- 
ations on  the  part  of  the  surgeon.  These  cases  should  all  be  under  the 
care  of  the  trained  observer  for  many  days  before  any  operation  is 
carried  out,  except  under  the  most  urgent  circumstances.  The  oper- 
ations should  be  performed  with  the  knowledge  that  more  than  familiar- 
ity with  surgical  cleanliness  and  technic  is  required  by  the  surgeon. 
Each  operation  should  be  planned  with  the  idea  of  reaching  and  remov- 
ing the  tumor,  not  with  the  idea  of  opening  the  skull,  and,  after  a 
hasty  examination,  doing  a  decompression.  Manifestly  this  calls  for 
the  possession  of  a  high  degree  of  neurologic  knowledge  by  the  surgeon 
as  well  as  the  internist. 

That  care  should  be  exercised  by  the  diagnostician  is  especially 
emphasized  when  one  remembers  that  while  there  are  known  focal 
centers,  there  is  a  large  "silent"  area  in  the  brain.  Association  fibers 
serve  to  confuse  the  picture  by  reacting  to  neighborhood  stimuli  and 
by  assuming  destroyed  functions  if  the  process  grows  slowly.  The 
most  important  factor  is  that  the  known  tracts  and  focal  centers  are 
so  closely  associated  that  involvement  of  one  will  produce  spurious 
signs  on  the  part  of  the  others.  Therefore,  it  follows  that  the  history 
of  the  development  of  the  tumor  is  of  the  greatest  importance.  The 
very  earliest  symptoms  should  be  painstakingly  sought  for,  since  in 
the  later  stages  the  pictures  become  almost  too  complex  for  under- 
standing; for  example,  the  early  deafness  may  serve  to  differentiate  a 

(327) 


328     TUMORS,   IXFLAMMATIOXS  AND  ABSCESSES  OF  BRAIN 

cerebellopontine  from  a  cerebellar  tumor.  In  general  we  should  always 
bear  in  mind  that  the  symptoms  fall  into  four  groups: 

A.  Those  produced  by  irritation  or  depression  of  the  neurological  or 
physiological  function  of  the  area  involved;  e.  g.,  monoplegic  motor 
paralysis,  or  acromegaly  associated  with  hypophyseal  disease. 

B.  Those  produced  by  irritation  or  depression  of  neurological  or 
physiological  function  in  adjacent  nervous  structures  and  changes  in 
other  adjacent  anatomical  structures;  f.  g.,  sensory  aura  in  motor 
tumors,  adiposity  in  third  A'entricle  hydrops,  changes  in  the  cerebro- 
spinal fluid,  and  the  enlarged  sella  turcica  in  h^^pophyseal  tumors. 

C.  Those  associated  with  the  nature  of  the  gro\Ai;h.  Here  we 
emphasize  the  coincident  systemic  tuberculosis  in  the  tubercles  of  the 
brain;  the  leukocytosis,  fever,  ear  and  nose  findings,  etc.,  associated 
with  abscess;  the  Wassermann  and  syphilitic  findings  in  gumma;  the 
destruction  of  tissue  and  rapid  growi;h  associated  with  sarcoma;  the 
cystic  degeneration  and  sudden  hemorrhage  with  consequent  signs 
found  in  gliomata;  evidences  of  carcinoma,  deciduoma  malignum, 
neurofibromatosis,  etc. 

D.  Those  produced  by  the  general  increase  of  intracranial  pressure. 
To  elicit  these  facts  a  most  careful  examination  is  necessary,  and 

the  neurological  student  will  do  well  to  familiarize  himself  with  a  defi- 
nite routine  in  his  investigation.  The  following  method  is  suggested. 
It  must  be  amplified  when  the  general  location  of  the  tumor  has  been 
found,  and  intensive  study  must  be  directed  to  this  location. 

I.  History  given  by  the  patient  of  the  mode  of  onset  and  course  of 
the  disease.  After  tlie  statement  is  made  by  the  patient,  it  must  be 
amplified  by  direct  questioning  bearing  on  the  points  brought  out  by 
the  patient  and  suggesting  new  correlative  data  for  the  patient  to 
accept  or  refuse  as  a  part  of  his  history.  Questions  should  be  asked 
concerning  sensory  and  motor  symptoms;  e.  g.,  spasms,  convulsions, 
anesthesia,  burnings,  and  tinglings.  The  date  of  the  onset  of  each  new 
sjTnptom  is  of  the  greatest  importance. 

n.  Family  history,  e.  g.,  s^-philis,  tuberculosis. 

HI.  Previous  disease,  and  if  a  woman,  obstetrical  history;  e.  g., 
sjT^hilis,  nephritis,  ear  disease,  nasal  disease,  injuries,  infected  mis- 
carriages. 

IV.  Examination. 

A.  General  physical  examination. 

B.  Examination  of  the  nervous  system. 

1.  Mental  functions,  e.  g.,  intelligence,  memory,  drowsi- 

ness, coma,  hallucinations. 

2.  Local  examination  of  head,  e.  g.,  local  tenderness, 

tumors,  thin  hair,  local  infection. 

3.  Cranial  nerves.    Examine  each  in  order  for  irritation 

and  paralysis.     Gross  tests  are  made  of  the 
second  and  eighth  anfl  these  reserved  for  full 
study  later, 
(a)  Smell. 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN         329 

(b)  Field  of  vision,  form,  color.     Ophthalmoscopic 

examination,  choked  disk,  atrophy,  hemor- 
rhages, choroiditis,  etc. 

(c)  (d)  (e)  Ocular  movements,  convergences,  diplopia, 

nystagmus.   Pupils — comparative  size,  shape, 

reaction  to  light,  accommodation. 
(/)  Sensation — face  and  mouth . 
(g)  Motor:  face,  forehead,  taste,  chorda  tympani  in 

anterior  two-thirds  of  tongue.    ]Mouth:  mas- 

seters,  temporals. 
(h)  Hearing — air  and  bone. 
(i)  Taste — posterior  third  of  tongue,  anesthesia  of 

pharjTix,  difficulty  of  swallowing. 
(0  Palate.    Heart.    Respiration.    Vocal  cords. 
(k)  IMotor — sternomastoid  and  trapezius. 
(/)    Motor — tongue. 

4.  Spinal  nerves. 

(a)  Motor — ^head,  neck,  arms,  intercostal  and  ab- 
dominal muscles,  legs.  Investigate  paralysis, 
paresis,  inco5rdination  in  gait,  and  adiado- 
kokinesia  and  pointing  tests,  atrophy. 

(6)  Sensory — subjective:  pain,  headache,  vertigo, 
tingling,  formication.  Objective:  absent  and 
increased  reaction,  touch,  pain,  temperature, 
stereognosis. 

5.  Reflexes. 

Superficial:  conjunctival,  palatal,  epigastric,  ab- 
dominal, cremasteric,  plantar,  anal.  Deep:  jaw, 
radial,  knee,  Achilles  tendon,  ankle-clonus,  knee- 
clonus,  Babinski. 

6.  Sympathetic :  proptosis,  exophthalmos,  local  or  general 

vasodilatation  or  contraction. 

7.  Functional  tests  and  examination:    speech,  bladder, 

rectum,  genital,    hypophyseal   adiposity,  growth, 
etc.,  pineal. 

8.  Special  laboratory  tests:    blood,  urine,  Wassermann 

spinal  fluid,  Abderhalden,  .r-rays,  brain  puncture. 
Cerebral  Localization. — General. — The  hope  of  relief  in  an  individual 
case  must  rest  upon  our  knowledge  of  functional  localization.  The 
difficulties  of  accurate  localization  rest,  not  so  much  upon  our  ignorance 
of  the  centers  for  special  function,  as  upon  the  fact  that  the  brain  is 
largely  made  up  of  association  centers  and  tracts,  so  that  although  we 
may  know  well  the  center  for  a  special  function,  we  may  yet  be  in 
doubt  in  a  given  case  as  to  whether  there  may  be  involvement  of  the 
center  itself,  of  the  fibers  leading  to  it,  or  away  from  it,  whether  there 
may  be  involvement  of  the  association  fibers  correlating  the  function, 
or  of  the  motor  fibers  expressing  the  function .  This  is  well  illustrated 
in  cases  of  aphasia  of  which  there  are  so  many  forms. 


330     TUMORS,  IX  FLA  M  MAT  I  OX  S  AXD  ABSCESSES  OF  BRAIX 

Galen  drew  attention  to  the  occurrence  of  contralateral  paralysis  in 
traumatic  lesions  of  the  head,  and  the  small  trephine  openings  over  the 
motor  areas  in  the  Peruvian  skulls  suggest  a  like  knowledge  by  these 
people.  Gall,  the  founder  of  phrenology,  must  be  given  credit  for  the 
revival  of  modern  study  upon  this  subject,  since  he  recognized  more 
clearly  than  his  predecessors  that  the  cerebral  hemispheres  were  the 
seat  of  intelligent  acts  and  functions,  although  Flourens  disproved  the 
assumption  Gall  made  as  to  their  seat.  Broca  in  1861  confirmed  the 
older  statements  of  Dax  that  aphasia  in  right-handed  people  was  asso- 
ciated with  a  lesion  of  the  third  frontal  convolution  of  the  left  side, 
hence  known  as  Broca's  convolution,  although  later  Marie  proved  the 
lack  of  constancy  of  this.  Hughlings  Jackson,  in  1SG4,  drew  attention 
to  localized  spasms  with  lesions  of  certain  parts  of  the  central  con- 
volutions. The  first  direct  evidence  of  motor  localization  was  brought 
forward  by  Fritsch  and  Hitzig  in  1870,  when  by  experiments  on  dogs 
they  showed  that  the  gray  matter  of  the  cortex  was  excitable  and  that 
by  irritation  at  specific  points  it  was  possible  to  produce  certain  move- 
ments. Ferrier  elaborated  and  confirmed  these  observ^ations  on  the 
monkey.  Horsley  later  added  much,  while  ."^chafer,  Beevor,  Gushing, 
Frazier,  and  many  others  have  contributed  both  experimental  and 
clinical  observations.  To  Sherrington  particularly,  we  owe  a  great 
debt  for  his  careful  and  painstakmg  studies,  especially  that  part  in 
which  he  demonstrated  that  the  motor  zone  lies  in  the  anterior  central 
convolutions. 

The  relations  of  the  various  convolutions  and  sulci  should  be  clearly 
understood  by  the  neurological  surgeon,  since  at  any  time  it  may  be 
necessary  for  him  to  enter  various  areas  for  exploration  or  the  extir- 
pation of  tumors.  The  sulci  are  most  vascular  and  should  be  avoided 
where  possible.  The  most  superficial  layer  of  the  brain  is  made  up 
largely  of  association  fibers;  consequently  destruction  of  this  layer 
may  not  lead  to  permanent  impairment  of  function.  A  microscopic 
section  will  show  the  following  cell  structure  from  the  cortex  inward, 
the  following  layers  with  approximate  thicknesses  as  follows:  (1) 
molecular,  0.34  mm.;  (2)  small  pyramidal,  0.90  mm.;  (3)  stellate  cells 
or  granular  layer,  0.22  mm.;  (4j  large  pyramidal — in  the  motor  area 
has  large  solitary  cells,  cells  of  Betz,  0.22  mm.;  (5)  polymorphous  cell 
layer,  0.31  mm. 

Roughly,  the  function  of  these  layers  may  be  classed  as  follows: 
the  pyramidal  cells,  associative;  the  granular  layer,  sensory;  the  large 
pyramidal  cells  of  Betz,  motor;  and  the  polymorphous  layer,  which 
presides  over  the  lower  functions  such  as  sexual  desire,  the  getting  of 
food,  etc.  From  the  cortex  the  various  fibers  pass  to  the  base  of  the 
bram  and  to  difterent  parts  making  groups  kno^^^l  as  projection, 
association,  and  commissural  fibers,  a  complete  discussion  of  which 
would  be  too  extensive  for  inclusion  here. 

Attention  should  be  dra\s'n  to  the  centers  for  the  cranial  nerves, 
smce  involvement  of  these  is  of  so  much  importance  in  localization. 
The  centers  and  function  of  the  first  eight  are  well  known.    When  the 


PLATE    II 


FIO.    I 


Cerebral  Localization. 

FIG.    2 


Cerebral  Localization. 

Note  the  large   number  of  centers  upon  the  vertex. 


TUMORS  AND  ALLIED  PROCESSES  IN   THE  BRAIN        331 

centers  for  the  others  are  involved  by  a  tumor  lying  along  the  aqueduct 
of  Sylvius  and  the  fourth  ventricle,  certain  reflex  acts  are  impaired, 
such  as  respiratory  and  vasomotor  function,  cardiac  inhibition,  masti- 
cation, deglutition,  sucking,  vomiting,  phonation,  articulation,  in 
addition  to  the  impairment  of  the  function  of  other  cranial  nerves. 
In  such  cases  we  speak  of  these  acts  as  if  they  had  a  special  center, 
e.  g.,  cardiac  center,  swallowing  center,  vasomotor  center,  etc.,  rather 
than  distinguishing  the  individual  nerve,  since  the  impaired  function 
can  seldom  be  referred  to  one  nerve  or  separated  from  others. 

The  "silent  area"  found  in  the  human  brain  is  largely  made  up  of 
association  fibers.  These  "silent  areas"  increase  in  amount  as  we 
ascend  the  scale  of  intelligence.  They  are  particularly  seen  in  the  loca- 
tions of  known  sensory  tracts  and  should  be  described  in  connection  with 
the  tract  with  which  they  are  most  closely  connected;  e.  g.,  the  visual- 
sensory  and  visual-association,  the  auditory-sensory  and  the  auditory- 
psychical.  This  also  serves  to  emphasize  the  difficulty  of  localization 
since  the  higher  we  go  in  the  scale  of  life  the  greater  must  be  the 
latitude  allowed  for  the  location  of  a  tumor  because  here  it  may  either 
involve  the  center  or  its  association  tract.  Thus  we  see  that  in  the 
future  the  knowledge  of  localization  must  come  from  intensive  study  of 
the  physical  findings  and  the  chronological  history  of  disease  in  each 
individual  case,  the  collection  of  numbers  of  such  observations,  and  the 
correlation  of  the  findings,  rather  than  from  experimental  observations 
on  lower  animals. 

The  most  satisfactory  results  of  localization  study  have  been  secured 
in  investigations  of  the  motor  area.  While  it  was  originally  believed 
that  the  motor  areas  extended  both  anteriorly  and  posteriorly  from  the 
central  fissure,  we  know  now,  thanks  to  the  investigations  of  Sherring- 
ton, that  they  are  located  anterior  to  the  fissure.  The  relation  of  these 
centers  may  be  seen  by  reference  to  the  accompanying  drawing  (Plate 
II),  showing  the  centers  as  depicted  by  Sherrington  and  others.  The 
motor  cells  extend  to  the  floor  of  the  central  fissure. 

In  operating  it  should  be  remembered  that  these  centers  lie  more  on 
the  vertex  than  on  the  side  of  the  brain.  In  dogs  the  ablation  of  these 
centers  produces  a  paralysis  from  which  the  dog  later  recovers;  in 
monkeys,  the  recovery  is  slower  and  less  complete;  while  in  man  a 
destruction  of  the  centers  produces  permanent  paralysis.  At  times, 
however,  we  see  recoveries  from  a  paralysis  apparently  complete,  but 
such  cases  are  probably  due  to  an  injury  of  the  association  tracts.  At 
times  such  a  paralysis  may  be  seen  clearly  to  be  outside  of  the  motor 
centers,  since  the  loss  of  motion  is  chiefly  in  relation  to  volitional  move- 
ments, e.  g.,  the  arm  may  be  paralyzed  yet  may  be  raised  in  association 
with  a  movement  involving  the  other  arm.  In  such  cases  a  small 
degree  of  recovery  may  be  noted. 

The  predominant  influence  of  the  motor  cortex  is  inhibitory  of  the 
stronger  muscles  of  the  body  and  the  tonus  which  is  constantly  main- 
tained. Thus  when  we  excite  the  motor  cortex,  an  inhibition  of  the 
postural  tone  and  of  the  antagonistic  muscles  is  brought  about  as  well 


332     TUMORS,   INFLAMMATIONS  AND   ABSCESSES  OF  BRAIN 

as  a  stimulation  of  the  muscles  directly  involved.  This  is  proved  by 
the  experimental  removal  of  the  cerebrum  in  dogs,  which  leads  to  gen- 
eral muscular  rigidity,  "decerebrate  rigidity"  so-called.  It  follows, 
therefore,  that  in  those  cases  in  which  the  inhibitory  function  of 
the  cerebnun  is  removed,  as  for  instance  where  conduction  through 
the  pyramidal  tracts  is  interfered  with,  we  will  have  spasticity  of  the 
muscles. 

Sherrington  and  Griinbaum  have  shown  by  experimental  observation 
that  tactile  and  muscular  sensibility  is  chiefly  related  to  the  central 
convolutions  including  those  anterior  to  the  central  fissure,  but  that 
they  are  especially  dependent  upon  the  postcentral  gyrus.    Starling, 


Pjq_  93_ — Endothelioma  of  forebrain.     (Northwestern  University  Medical  School 

collection.) 


to  whom  I  am  indebted  for  abstracts  freely  taken,  says  that  Fleshsig 
has  shown  that  fibers  from  the  thalamus  which  may  probably  be 
regarded  as  continuations  of  the  fillet  system,  are  also  distributed  to 
other  portions  of  the  cortex,  i.  e.,  temporal,  frontal,  and  occipital  lobes. 
It  is  therefore  not  surprising  that  the  hemi-anesthesias  produced  by 
lesions  of  the  central  convolutions  are  rarely  or  never  complete. 

The  senses  of  pain  and  temperature  probably  lie  in  the  intermediate 
postcentral  zone  of  Campbell,  i.  e.,  in  the  posterior  part  of  the  post- 
central gyrus,  and  stereognostic  sense  in  the  parietal  lobe. 

Special. — Frontal  Lobes. — The  third  left  frontal  lobe — Broca's  con- 
volution— has  long  been  considered  as  the  center  for  motor  speech 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN        333 

and  undoubtedly  we  do  at  times  find  an  impairment  of  speech  from 
tumors  located  here;  but  whether  this  impairment  is  due  to  destruc- 
tion of  the  tissue  at  that  area  or  to  pressure  upon  adjacent  brain-tissue, 
is  open  to  question.  At  the  present  time,  for  the  reasons  mentioned 
below,  when  discussing  temporal  lobe  tumors,  considerable  doubt  must 
be  thrown  upon  this  assumption. 

The  presence  of  psychical  disorders  has  also  been  ascribed  to  tumors 
of  the  frontal  lobes,  but  it  must  be  admitted  that  these  phenomena 
may  be  associated  with  tumors  in  any  part  of  the  brain,  as  Miiller  has 
shown,  and  probably  they  have  little  localizing  value.  Franz  has 
shown  by  experiments  on  monkeys  that  destruction  of  the  frontal  lobes 
causes  loss  of  recently  formed  habits.  He  concludes  that  the  frontal 
lobes  are  the  means  by  which  we  are  able  to  learn  and  form  habits, 
that  is,  to  regulate  our  behavior  in  accordance  with  the  needs  of  our 
position  in  society. 


Fig.  94. — Tuberculomata  of  cortex — monoplegic  signs  in  the  early  stages. 
(Northwestern  University  Medical  School  collection.) 

Bruns  first  drew  attention  to  rigidity  of  the  neck  and  cerebellar 
ataxia  and  thought  these  symptoms  were  due  to  tumors  lying  in  the 
marginal  gyrus  and  the  corresponding  portion  of  both  frontal  lobes. 
Granger  and  Stewart  have  drawn  attention  to  the  disappearance  of  the 
abdominal  and  epigastric  refiex  on  the  opposite  side  and  a  fine  tremor 
on  the  same  side  which  they  have  shown  in  some  cases  by  holding  the 
extremities  outstretched.  This  finding  is  not  constant,  however,  and 
when  present  is  most  often  seen  in  the  arm.  Petit  mal  may  be  seen. 
Early  and  persistent  anosmia  due  to  pressure  on  the  olfactory  nerve 
may  be  seen  in  tumors  beginning  on  the  under  surface. 

Motor  and  Sensory  Zones. — Tumors  of  the  cortical  motor  zone  lying  for 
the  most  part  in  the  anterior  central  gyrus  give  contralateral  signs,  those 


334     TUMORS,   IXFLAMMATIOXS  AXD  ABSCESSES  OF  BRAIX 

upon  or  near  the  surface  being  characterized  by  irritati\e  s^Tnptoms; 
e.  gi.,  epilepsy  followed  by  paralysis,  the  latter  being  primarily  monoplegic 
— brachial,  facial — and  later  more  general  (Fig.  94).  The  deeper  the 
tumor  lies,  the  less  irritative  it  becomes  and  the  more  a  paralysis  may 
precede  convulsions.  Moreover,  the  extent  of  paralysis  is  great  early 
in  its  course  extending  even  to  a  complete  hemiplegia  at  the  internal 
capsule  or  above  (Fig.  95).  Hemorrhage  into  a  tumor,  for  instance  into 
a  glioma,  may  produce  a  sudden  paralysis.  Paracentral  lobule  tumors 
may  give  bilateral  symptoms. 

Owing  to  the  juxtaposition  of  the  sensory  areas  in  the  posterior 
central  g^Ti,  the  convulsive  attacks  are  frequently  preceded  by  aura, 
such  as  paresthesia  in  a  part  of  an  extremity — burning  in  the  dis- 
tribution of  a  nerve  of  the  foot.     As  the  growth  extends  into  these 


Fig.  95. — Central  glioma — early  hemiplegia. 

areas  the  evidences  become  more  marked  although  complete  hemi- 
anesthesia is  seldom  produced.  There  may  be  impairment  of  tactile 
sensibility  alone,  or  all  t^-pes  of  cutaneous  sensibility  may  be  affected. 
The  sense  of  position  ma>'  be  affected.  Complete  and  persistent 
analgesia  and  thermo-anesthesia  are  apparently  never  caused  by  cir- 
cumscribed cortical  foci. 

Astereognos's,  i.  e.,  the  loss  of  ability  to  recognize  objects  by  palpation, 
may  be  seen,  especially  in  tumors  of  the  postcentral  g^Tus.  The  deeper 
the  timior  lies,  the  more  extensive  the  anesthesia,  although  it  is  seldom 
characteristically  hemilateral  unless  the  lesion  involves  the  posterior 
zone  of  the  internal  capsule  or  the  corresponding  ganglion  masses  in 
the  optic  thalamus,  or  the  complete  bundles  in  theu-  course.  Symptoms 
of  sensory  irritation,  e.  g.,  contralateral  pain,  are  uncommon  in  cortical 
lesions  but  may  accompany  deeper  foci. 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN        335 

Temporal  Lobes. — ^The  centers  definitely  established  for  the 
temporal  lobes  are  the  bilateral  ones  for  taste  and  smell  and  the  left 
unilateral  center  in  right-handed  individuals  for  sensory  appreciation 
of  speech.  However,  owing  to  the  pressure  of  tumors  upon  adjacent 
areas,  the  symptoms  in  these  cases  may  be  most  complex.  Tumors 
involving  the  median  area  of  the  temporal  lobes,  the  gyrus  fornicatus, 
and  the  uncus,  give  rise  to  the  so-called  uncinate  fits,  an  attack  begin- 
ning with  a  disturbance  of  taste  or  smell,  generally  most  unpleasant, 
followed  by  a  dreamy,  confused  state  or  semi-unconsciousness  lasting 
several  seconds.  These  attacks  may  be  accompanied  by  motor  phe- 
nomena, such  as  smacking  of  the  lips  or  even  convulsions. 

It  should  be  remembered  that  direct  pressure  upon  the  first  nerve 
may  produce  similar  sensations.  The.  exact  location  and  limitations 
of  the  centers  for  taste  and  smell  are  still  undetermined.  In  animals, 
with  these  senses  highly  developed,  marked  growth  is  seen  in  the 
olfactory  lobe  including  the  bulb,  the  dentate  convolution  with  the 
hippocampal  gyrus,  the  part  of  the  gyrus  fornicatus  encircling  the 
corpus  callosum  and  the  anterior  commissure.  To  these  areas  the  sense 
of  taste  and  smell  are  generally  ascribed  but  nothing  definite  is  known. 

Owang  to  the  complexity  of  the  function  of  speech,  the  exact  location 
of  the  centers  controlling  it  is  somewhat  doubtful.  It  is  thought  that 
sensory  aphasia,  word  deafness,  loss  of  the  power  of  understanding 
speech,  may  be  produced  by  a  lesion  of  the  posterior  part  of  the  first 
left  temporal  convolution  or  in  the  angular  or  supramarginal  gyri; 
while  pure  alexia,  word  blindness,  occurs  with  destruction  of  the 
posterior  part  of  the  third  left  temporal  convolution. 

It  must  be  remembered  that  these  are  not  centers  in  the  strict  inter- 
pretation of  the  word,  but  are  really  association  tracts,  and  that  inter- 
ruption at  various  points  will  give  varying  types  of  aphasia.  Broca's 
convolution  in  the  frontal  lobe  has  long  been  considered  as  the  motor 
center,  but  reports  of  clinical  cases  of  tumors  in  this  region  without 
impairment  of  speech — a  condition  which  has  been  especially  studied 
by  Marie — combined  with  the  experimental  evidences  that  this  center 
can  be  destroyed  without  harm,  and  with  microscopic  proof  that  the 
cells  do  not  resemble  those  of  known  motor  areas,  all  cast  doubt  upon 
this  assumption.  It  should  not  be  forgotten,  however,  that  tumors  in 
this  region  have  produced  loss  of  speech;  whether  due  to  local  destruc- 
tion or  pressure  upon  adjacent  areas  may  be  open  to  question.  It  is 
thought  by  some  that  pure  motor  aphasia  is  to  be  associated  with  a 
lesion  of  the  lenticular  nucleus  or  its  neighborhood,  in  the  anterior 
part  of  the  genu  of  the  internal  capsule  and  possibly  of  the  external 
capsule. 

It  should  be  noted  that  temporal  lobe  tumors  may  cause  convulsions 
or  disturbance  of  consciousness  which  are  ushered  in  by  auditory 
aura,  such  as  tingling  and  whistling  in  the  opposite  ear.  If  the  tumors 
lie  deeply,  pressure  upon  the  posterior  end  of  the  internal  capsule  may 
produce  contralateral  hemianesthesia  or  even  hemiplegia;  likewise 
hemianopsia  may  appear  in  the  contralateral  half  of  both  visual  fields 


336     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

due  to  in^•ol^•ement  of  the  underlying  optic  rafliation.  Pressure  upon 
the  optic  thalamus,  since  it  is  a  reflex  center  for  emotional  expression, 
may  produce  marked  diminution  of  emotional  expression  upon  the 
opposite  side  of  the  face. 

Occipital  Lobe. — Since  the  occipital  lobe  is  the  center  of  vision,  the 
characteristic  evidence  of  tumor  here  is  disturbance  of  the  visual  sense 
(Plate  III).  The  center  is  situated  on  the  mesial  aspect  for  the  most 
part,  lying  partly  above  and  partly  below  the  calcarine  fissure.  The 
lower  quadrant  of  the  half  field  is  represented  above  the  fissure,  i.  e., 
in  the  cuneate  lobule;  the  upper  quadrant  below,  i.  e.,  in  the  lingual 
lobule.  It  follows  that  in  rare  cases,  temporonasal  hemianopsia  may 
be  seen  and  in  extremely  rare  cases,  quadrate  blindness.  Evidences  of 
irritation  may  be  seen  in  hallucinations  of  vision  such  as  flashes  of 
light.  These  frequently  precede  hemianopsia,  but  may  be  met  in  the 
blind  area  later.  Bruns  says  choked  disk  is  rare.  Wernike's  hemiopic 
pupillary  phenomenon  of  course  is  absent. 

."Wernike's  hemiopic  pupillary  phenomenon  is  an  absence  of  pupil- 
lary contraction  when  a  ray  of  light  is  thrown  on  the  blind  half  of  the 
retina  of  an  eye  ha\'ing  hemianopsia.  It  signifies  a  lesion  of  the  visual 
path  behind  the  chiasma  and  below  or  at  the  corpora  quadrigemina.  In 
retroquadrigeminal  hemianopsia,  where  the  lesion  is  anj-w^here  between 
the  corpora  quadrigemina  and  the  visual  cortex,  the  pupillary  reaction 
is  normal."     (Stewart.) 

Central  Gray  Matter. — Tumors  lying  in  the  central  gray  matter 
and  basal  ganglia  and  in  the  wall  of  the  third  ventricle,  produce  the 
general  symptoms  of  brain  tumor  with  varying  phenomena  as  the 
different  centers  may  be  involved.  The  picture  is  often  most  complex. 
Weisenberg  has  collected  the  literature  and  classified  tumors  of  the 
third  ventricle  as  follows: 

"  1.  Those  cases  in  which  a  tumor  of  moderate  size  is  situated  in  the 
floor  of  the  third  ventricle  and  in  which  there  is  no  extension  into  the 
foramen  of  Monro  or  aqueduct  of  Syhius. 

"2.  Small  tumors  so  situated  as  to  obstruct  the  foramen  of  Monro, 
the  position  of  which  can  be  changed  by  deviation  of  the  head. 

"3.  Those  tumors,  whether  large  or  small,  which  either  extend  into 
the  aqueduct  of  Sylvius  affecting  the  surrounding  structures  by  direct 
extension  or  pressure,  or  those  in  which  the  posterior  portions  of  the 
cerebral  peduncles  and  pons  are  compressed,  either  by  direct  pressure 
or  by  dilatation  of  the  aqueduct  of  Sylvius. 

"The  first  class  does  not  offer  specific  symptoms,  but  present  evi- 
dences of  internal  hydrocephalus,  viz.,  headache,  choked  disk,  nausea, 
vomiting,  and  dizziness.  In  tumors  of  large  size,  indirect  ])ressure  upon 
the  internal  capsule  causes  paresis  of  the  corresponding  limbs.  These 
symptoms  may  likewise  result  from  internal  hydrocephalus  alone.  The 
reflexes  are  nearly  always  increased.  The  mental  symptoms,  generally 
supposed  to  be  present  in  tumors  of  the  third  \entricle,  are  attril^uted 
by  Mott  to  impairment  of  the  function  of  the  cortex  as  a  result  of  the 
pressure  of  the  dilated  ventricles. 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN        337 

"The  second  class  is  unimportant  as  but  one  case  has  been  observed. 
This  group  presents  a  variation  in  sj^mptoms  of  headache,  nausea  and 
impairment  of  vision  upon  tilting  the  head  forT\''ard. 

"The  thu'd  class  offers  a  fairly  well-recognizable  s\Tnptom-complex. 
The  sjmaptoms  arise  from  involvement  of  the  third  nerve  nuclei,  red 
nucleus,  or  superior  cerebellar  peduncles  and  from  pressiue  upon,  or 
destruction  of,  the  posterior  longitudinal  bundle  or  the  intercommuni- 
cating fibers  between  the  third  nuclei.  Among  the  symptoms  noted 
are  disturbance  of  associated  ocular  movements,  oculomotor  palsies, 
large  pupils  with  impaired  reaction,  protrusion  of  the  eyebahs,  cere- 
bellar ataxia,  sjinptoms  arising  from  pressure  upon  the  pineal  gland, 
and  the  general  sjinptoms  of  tumor  cerebri." 

In  central  tumors  the  internal  capsule  is  generally  affected  with 
consequent  hemiplegia.  In  Oppenheim's  experience,  the  facial  is  fre- 
quently first  involved,  accompanied  by  impairment  of  the  reflexes  as 
in  pjTamidal  involvement.  There  may  be  motor  excitability,  contra- 
lateral hemichorea,  or  athetosis,  increased  on  voluntary  motion; 
hemianesthesia;  hemianopsia.  Many  thalamic  tumors  may  have  no 
symptoms  while  in  other  cases  contralateral  movements  as  above,  due 
to  adjacent  rubrospinal  tract  involvement,  may  be  seen  accompanied 
at  times  by  contralateral  subjective  sensations  of  heat,  cold,  pain,  etc. 

Corpus  Callosiim. — ^There  are  no  definite  signs  of  lesion  in  the 
corpus  callosum.  Bristow  has  given  the  following  symptom-'complex 
as  suggestive :  slight  signs  of  general  pressure  with  marked  impairment 
of  intelligence,  hebetude,  hemiparetic  sjonptoms  followed  by  involve- 
ment of  the  opposite  side  and  absence  of  involvement  of  cranial  nerves. 
Large  incisions  may  be  made  through  the  corpus  callosum  without 
serious  permanent  sjmiptoms. 

Cerebelloi. — The  complex  functions  of  the  cei'ebellum  have  been 
a  fruitful  soiu-ce  of  study.  The  sjTnptoms  of  tumor  growth  are  better 
understood  if  we  remember  that  complete  unilateral  extirpation  in 
animals  gives  rise  to  three  sjTnptoms;  slight  loss  of  power  upon  the 
same  side  of  the  body,  asthenia;  considerable  loss  of  tone  on  the  same 
side,  atonia;  tremors  or  rh}i;hmical  movements  of  muscles  on  the 
same  side  accompanying  any  willed  movement,  astasia.  An  animal 
so  affected  lies  upon  the  same  side,  being  unable  to  stand,  the  head  and 
neck  are  ciu-ved  to  the  side  on  which  it  lies,  and  upon  attempting  to 
stand,  the  animal  falls  to  the  same  side.  After  a  time  although  it  may 
stand,  it  has  the  sjonptoms  mentioned  above.  Sherrington  concludes 
from  such  investigations  that  the  cerebelliun  is  the  head  ganglion  of  the 
proprioceptive  system  acting  as  a  center  to  which  are  sent  the  afferent 
impulses  from  the  cord,  fifth  nerve,  and  especially  the  lab\Tinth.  "It 
furnishes  the  subconscious  basis  for  the  guidance  of  the  motor  functions 
of  the  cerebrum.  Through  its  connections  with  the  bulb  it  augments 
the  tonic  activity  of  the  muscles  and  consequently  when  the  cerebrum 
is  removed,  gives  rise  to  rigidity  of  the  body  known  as  'decerebrate 
rigidity.'"     (Sherrington.) 

The  symptoms  of  tumors  as  emphasized  by  Stewart,  Oppenheim, 

VOL.  I — 22 


338     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

Hoppe,  and  others,  may  be  summarized  as  follows:  Stewart  and 
Holmes  have  described  a  typical  picture  of  lateral  lobe  tumors  in  which 
symptoms  appear  upon  the  ipsolateral  side  consisting  of  paresis, 
diminished  muscular  tone,  asynergia  on  voluntary  movements,  espe- 
cially in  the  arm,  weakjiess  of  conjugate  movements  of  the  eye  toward 
lesion,  horizontal  nystagmus  on  the  ipsolateral  side,  and  su})jective 
vertigo  in  which  objects  appear  to  rotate  toward  the  contralateral 
side.  Adiadokokinesia  and  insecurity  in  standing  on  the  ipsolateral 
side  are  therefore  important  signs.  Oppenheim,  Spillar,  Hoppe,  and 
others  have  found  these  symptoms  at  times,  but  again  they  may  be 
absent. 

Vertigo  with  loss  of  equilibrium  and  nystagmus  without  a  preponder- 
ance of  ataxia  on  either  side  are  seen  especially  in  vermis  tumors. 
Cerebellar  "fits"  have  been  seen  in  a  few  cases.  These  are  character- 
ized by  tonic  spasms,  sudden  in  onset,  esp.ecially  in  the  face  on  ipso- 
lateral side.  The  ipsolateral  leg  is  adducted,  the  contralateral  abducted 
and  there  is  a  screwlike  rotation  of  the  limbs,  trunk,  and  head  about 
their  own  long  axis. 

Cerebellar  tumors  may  be  latent  or  atypical.  The  symptoms  also 
vary  with  the  location  of  the  tumor.  The  extracerebellar  tumors 
naturally  give  rise  to  extracerebellar  symptoms  early,  and  intracere- 
bellar,  late;  e.  g.,  pressure  or  irritation  of  fifth,  seventh,  eighth,  and 
other  cranial  nerves,  pressiu'e  on  pons,  with  alternating  hemiplegia 
and  paralysis  with  conjugate  de\iation  toward  the  side  of  the  tmnor, 
pressure  upon  the  medulla  with  its  centers  and  nerves,  pressure  upon 
the  pjTamidal  tracts,  with  hemiparesis  and  paraparesis  spastic  in 
nature,  pressure  obstructing  the  flow  of  the  cerebrospinal  fluid  with 
hydrocephalus  with  pressure  upon  the  optic  nerve  and  blindness,  also 
anosmia,  occipital  lobe  symptoms,  and  increased  intraspinal  pressure 
possibly  destroying  knee-jerks.  The  general  SAinptoms  are  prominent; 
vomiting  is  quite  constant,  bilateral  choked  disk  appears  early,  head- 
ache is  most  often  in  the  occipital  region  accompanied  by  pain  in  the 
neck  and  the  upper  part  of  the  back,  but  it  may  be  in  the  frontal 
region. 

Cerebellofoxtixe  Axgle  .^Tumors  here  if  typical  in  onset  are 
easily  recognized.  In  this  region  as  elsewhere,  a  study  of  the  symptoms 
in  their  chronologic  order  is  of  the  greatest  importance.  Since  the 
timior  is  frequently  a  nem-ofibroma  or  endothelioma  growmg  from  the 
eighth  nerve,  the  patient  gives  a  history  of  a  slowly  developing  buzzing 
or  ringing  in  the  affected  ear  followed  by  deafness.  The  coincident 
or  subsequent  involvement  of  the  fifth,  sixth  and  se\enth  nerves  gives 
sjTnptoms  ordinarily  ushered  in  by  burning  or  tingling  over  the  face 
on  the  same  side  and  loss  of  corneal  reflex.  This  is  accompanied  or 
followed  by  evidences  of  pressure  upon  the  cerebellum,  pons,  and 
medulla;  vertigo,  ataxia,  nystagmus,  paralysis  of  conjugate  deviation, 
and  bulbar  symptoms.  General  symptoms  of  brain  pressure  develop 
early.  The  absence  of  these  and  a  tendency  to  bilateral  involvement 
tend  to  differentiate  the  tumors  of  the  pons  from  the  tumors  of  the 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN        339 

cerebellopontine  angles,  while  in  cerebellar  growths  the  cerebellar 
symptoms  precede  the  nerve  symptoms  and  are  more  marked.  A 
somewhat  similar  picture  may  be  produced  by  basilar  syphilis  or 
meningitis,  by  sarcomata  growing  from  the  meninges,  gliomata  growing 
from  the  ventral  surface  of  the  cerebellum,  as  well  as  by  other  tumors 
of  the  immediate  neighborhood. 


Fig.  96. — Cerebellopontine  tumor.  This  patient  presented  but  few  of  the  typical 
symptoms  of  cerebellopontine  angle  tumors,  ha\'ing  no  definite  paralysis  of  the  seventh 
or  other  cranial  nerve  symptoms.  The  slight  weakness  in  the  left  arm  and  leg  with  a 
history  of  some  slight  impairment  of  auditory  function  combined  with  the  evidences  of 
general  brain  pressure  led  us  to  do  suboccipital  operation.  The  tumor  was  found  and  a 
considerable  area  scraped  away  but  owdng  to  cardiac  symptoms  appearing  due  probably 
to  pressure  on  the  vagus  whenever  the  tumor  was  touched  in  its  deeper  part,  the  operation 
was  discontinued.  The  patient  recovered  from  the  immediate  operation  but  died  six 
weeks  later  of  brain  pressure.     (Wesley  Memorial  Hospital,  No.  56035.) 

Pons  and  Medulla  Oblongata. — The  tumors  of  the  pons  are 
most  often  gliomata  or  tuberculomata,  and  the  local  signs  are  more 
marked  than  the  general.  Choked  disk  is  generally  absent.  The 
typical  picture  is  that  of  a  hemiplegia  alternans,  presenting  commonly 
a  paralysis  of  the  fifth,  sixth  and  seventh  nerves,  on  the  ipsolateral, 
and  the  extremities  on  the  contralateral  side.  The  eighth  nerve  may 
be  involved  on  one  or  both  sides,  and  the  third  on  the  same  side.  The 
seventh  may  be  the  only  nerve  involved  early,  and  Oppenheim  has 
reported  several  cases  in  which  long  before  paralysis  of  the  opposite  leg, 
the  patient  presented  ipsolateral  facial  paralysis,  paralysis  of  conjugate 
deviation,  and  Babinski's  reflex  on  the  contralateral  leg.  He  has  also 
drawn  attention  to  conjugate  deviation  of  the  eyes  and  the  turning  of 
the  head  toward  the  contralateral  side.  In  the  majority  of  cases,  owing 
to  the  extension  of  the  tumor,  there  soon  develops  bilateral  paralysis 
of  the  cranial  nerves  and  the  extremities,  accompanied  by  dysarthria 


340     TUMORS,   INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

and  dysphagia.  Less  often  owing  to  extension,  pressure,  or  location 
in  the  dorsal  region  of  the  pons,  we  may  have  sensory  disturbances, 
hemiataxia,  or  convulsions. 

The  tumors  of  the  medulla  have  many  symptoms  in  common  with 
pure  pontine  tumors,  except  that  they  involve  the  eighth  to  twelfth 
nerves  more  prominently  giving  rise  to  deafness,  difficulty  in  swallowing 
and  respiration,  hiccough,  dysarthria  accompanied  by  irregular  heart, 
and  at  times  glycosuria,  diabetes  insipidus,  and  vasomotor  phenomena. 
Pressure  on  the  cerebellum  may  produce  cerebellar  symptoms. 

Cerebral  Peduncles. — Tegmental  Region. — Due  in  all  probability 
to  involvement  of  the  red  nucleus,  we  have  here  the  so-called  "  Bene- 
dikt's  syndrome"  consisting  in  an  ipsolateral  paralysis  of  the  third 
nerve  with  contralateral  paresis  accompanied  by  an  intention  tremor 
of  the  type  of  paralysis  agitans  or  chorea,  due  to  an  interruption  of  the 
rubrospinal  tract  (Monakow's  bundle).  This  tremor  has  been  found 
in  eight  out  of  eighteen  peduncular  tumors  reported.  If  the  growth 
involves  the  median  fillet,  we  have  contralateral  anesthesia. 

Ventral  Region. — Here  we  have  incomplete  third  nerve  palsy  of  the 
ipsolateral  side,  and  contralateral  hemiplegia — ^face,  arm  and  leg — 
usually  associated  with  spasticity.  Owing  to  the  close  relation  of  the 
nuclei  of  the  third  nerve,  the  growth  early  produces  a  bilateral  paralysis 
of  this  nerve  (nine  out  of  eighteen  cases). 

Corpora  Quadrigemina. — These  tumors  generally  involve  the 
lateral  geniculate  body,  the  subcortical  auditory  center  in  the  posterior 
corpora  quadrigemina,  the  third  and  frequently  the  sixth  nerves,  and 
in  addition  in  advanced  cases  press  upon  the  cerebellar  peduncles. 
The  commonest  symptom  is  a  combination  of  bilateral  ptosis  with 
weakness  of  upward  and  downward  movements  of  the  eye  and  feeble- 
ness of  convergence.  The  pupillary  reflex  may  be  sluggish  or  absent. 
Amblyopia  or  hemianopsia,  due  to  injury  of  the  external  geniculate 
body,  is  frequently  seen,  or  complete  blindness  may  be  present.  The 
peduncular  pressure  gives  ataxia  on  walking  or  standing  with  no  loss 
of  sensation.  Deafness  is  less  constant.  Intention  tremors,  athetosis, 
and  vasomotor  changes  may  be  seen,  while  nystagmus  is  common. 

Hypofhysis. — Tumors  of  the  hypophysis  give  rise  to  symptoms 
first  because  of  perversion  of  secretion,  and  second  because  of  pressure 
upon  adjacent  structures. 

Perversion  of  Secretion. — Our  present  conception  of  the  functions 
of  the  hypophysis  and  consequently  the  symptoms  due  to  their  per- 
version is  largely  due  to  the  painstaking  work  of  Cushing,  Crowe,  and 
Goetsch,  and  their  associates. 

The  work  of  Cushing  and  his  monograph  detailing  his  investigations 
— "  The  Pituitary  Body  and  its  Disorders" — will  long  stand  as  a  monu- 
ment to  American  scientific  endeavor.  He  has  subdivided  and  classi- 
fied the  functions  of  the  gland  although  naturally  there  is  still  much 
uncertainty  and  controversy  concerning  them.  Whether  the  symp- 
toms may  be  due  to  a  hyposecretion  or  hypersecretion  or  a  dyspitui- 
tarism  in  various  cases,  must  still  be  decided;  also  whether  the  anterior 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN        341 

or  posterior  lobe  or  the  pars  intermedia  may  be  the  source  in  an  indi- 
vidual state.  It  is  manifest  that  there  may  be  an  excessive  activity  of 
one  and  a  lessened  activity  of  another  at  the  same  time.  Lewis  has 
drawn  particular  attention,  and  with  justice  it  seems  to  me,  to  the 
function  of  the  pars  intermedia  and  attributes  in  great  measure  to  this 
the  functions  assigned  to  the  posterior  lobe  by  Gushing.  At  the  present 
time  it  seems  justifiable  to  assign  growth  to  the  anterior  lobe  and 
functional  changes;  e.  g.,  fat  deposit,  polyuria,  etc.,  to  the  pars  inter- 
media or  posterior  lobe;  a  hyperpituitarism  before  the  age  of  ossifica- 
tion of  the  epiphyses  gives  rise  to  gigantism  and  acromegaly;  after 
ossification  to  acromegaly,  accompanied  by  excessive  growth  of  hair  and 
overactivity  of  the  sebaceous  follicles  in  the  skin,  while  the  anterior 
lobe  hypopituitarism  is  accompanied  by  lack  of  bony  growth,  absence 
of  hair,  and  soft  skin  characteristic  of  childhood.  Posterior  lobe  insuffi- 
ciency (Gushing)  produces  adiposity,  high  sugar  tolerance,  subnormal 
temperature,  slow  pulse,  asthenia  and  drowsiness.  Polyuria  probably 
accompanies  changes  in  the  pars  intermedia. 


Fig.  97. — See  Fig.  98.     The  right  eye  was  completely  atrophied.     (Wesley  Memorial 

Hospital,  No.  46392.) 


It  is  manifest  that  the  clinical  picture  will  vary  with  the  type  of 
tumor  and  as  to  whether  it  stimulates  an  excessive  secretion  or  impairs 
the  secretory  activity  (Figs.  97  and  98).  Moreover,  this  picture  may 
change  from  an  excessive  to  an  underactivity  at  any  stage  in  the  pro- 
gress of  the  disease.  We  have,  however,  certain  general  symptom 
groups  that  accompany  disease  of  this  gland. 

Froelich  has  classified  the  group  accompanying  certain  preadolescent 
tumors,  consisting  essentially  in  a  lack  of  development  beyond  the  age 
of  puberty— no  growth  of  body  hair,  aplasia  of  the  genitalia,  with 
lack  of  function,  lack  of  general  bony  growth — to  which  is  added  per- 
version of  secretion  producing  an  excessive  deposit  of  fat.  This  type 
is  frequently  accompanied  by  cystic  degeneration  of  the  anterior  lobe 
or  anlage  from  the  primitive  pharynx  lying  in  the  sella  turcica,  but  may 
accompany  other  tumors,  such  as  adenomata.    The  adenoma,  however, 


342     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

is  more  characteristic  of  the  tumors  developing  later  in  life  giving  rise 
to  gigantism  and  acromegaly  characterized  especially  by  excessive 
bony  growth,  hj^pertrichosis,  excessive  thickness  of  skin,  excessive 
gland  secretion  supposed  to  be  due  to  anterior  lobe  hypersecretion, 


P'iG.  98. — Hypopituitarism.  Girl,  aged  eighteen  j^ears,  cyst  of  hj^Dophysis.  No  develop- 
ment after  age  of  puberty,  but  no  excessive  fat  deposit.  (Wesley  Memorial  Hospital, 
No.  46392.) 

followed  by  posterior  lobe  insufficiency,  deposit  of  fat,  high  sugar 
tolerance,  mental  deterioration,  etc.  (Fig.  99). 

The  etiology  of  adiposis  is  still  under  discussion.  It  has  been  found 
accompanying  tumors  of  the  pars  nervosa  and  the  anterior  lobe  of  the 
hypophysis,  tumors  in  the  neighborhood  of  the  hypophysis,  destruction 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN        343 

of  the  h\-pophysis  by  a  bullet,  and  not  to  be  forgotten,  accompanying 
hydrocephalus  of  the  third  ventricle  produced  by  pineal,  quadrigeminal, 
third  ventricle,  and  cerebellar  tumors.  Pollock  has  drawn  especial 
attention  to  the  results  of  this  latter  type  of  hydrocephalus. 


Fig.  99. — Acromegaly.  Photograph  of  patient  and  sella.  In  spite  of  the  evident 
enlargemeTit  of  the  sella  and  the  marked  signs  of  acromegaly  no  operation  has  been 
performed,  since  there  is  no  impairment  of  \dsion  and  the  disease  has  apparently  been 
stationary  for  fifteen  years.     (Wesley  Alemorial  Hospital,  No.  53277.) 


Certain  hypophyseal  tumors  grow  so  rapidly  as  to  produce  only 
pressure  symptoms  (Figs.  100,  101  and  102),  while  on  the  other  hand 
neighborhood  tumors  and  those  causing  third  ventricle  hydrocephalus 
may  produce  functional  changes  as  noted  above,  especially  those  due 
to  posterior  lobe  insufEciency  (Fig.  103.) 


344     TUMORS,  IXFLAMMATIOXS  AXD   ABSCESSES  OF  BRAIX 

Pressure  Symptoms. — Pressure  upon  the  surrounding  bony  structures 
produces  either  an  enlargement  of  the  sella  turcica  or  destruction 


Fig.  100. — Sarcoma  of  lij'pophysis.  Girl,  aged  fourteen  years.  Patient  died  six  months 
after  palliative  partial  hypophysectomy.  Symptoms  developed  rapidly.  Xo  eWdences 
of  perversion  of  secretion.  Early  blindness  and  enlarged  sella  led  to  diagnosis.  (Wesley 
Memorial  Hospital,  No.  47897.) 

especially  of  the  posterior  wall.  While  tumors  may  grow  out  of  the 
sella  turcica  without  causing  enlargement  we  are  always  loath  to  make 
a  positive  diagnosis  without  it.    The  enlargement  of  the  sella  practi- 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN 


345 


cally  always  accompanies  the  Froelich  type,  and  frequently  the  acro- 
megalic. Sarcomata  are  apt  to  produce  destruction  of  bone.  An 
absence  of  the  posterior  wall  of  the  sella  turcica  does  not  necessarily 
mean  a  sarcomatous  destruction,  since  an  aplasia  due  to  pressure  in 
early  life  may  be  seen.  In  sarcomatous  destruction  a  fragmentation  is 
often  noted,  but  this  also  may  be  present  as  a  result  of  benign  growth. 


Fig.  101. — Glioma  of  hypophysis.  Girl,  aged  fifteen  years.  Early  blindness  and 
change  in  sella,  with  lack  of  hair  and  other  evidences  of  perversion  of  secretion,  led  to 
diagnosis.  Convulsive  seizures  and  marked  brain  pressure  symptoms  are  explained  by 
the  growth  of  the  tumor  into  the  third  ventricle  (see  cut  section)  and  surrounding  tissue 
with  consequent  hydrocephalus.     (Wesley  Memorial  Hoefpital,  No.  52242.) 


The  second  most  important  symptom  is  pressure  upon  the  optic 
nerve.  Theoretically  the  tumor  should  produce,  because  of  its  location, 
a  bitemporal  hemianopsia,  and  while  this  frequently  occurs,  its  absence 
does  not  contra-indicate  the  diagnosis.  A  glance  at  the  accompanying 
chart  modified  from  Stewart,  will  show  how  the  picture  may  vary 
according  to  the  pressure  exerted  (Plate  III).  There  is  frequently 
a  history  of  transient  attacks  of  blindness;  amaurosis  may  be  seen. 
These  patients  may  first  consult  the  oculist  and  because  of  the  varying 


346     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

fields  a  preliminary  diagnosis  of  hysteria  is  frequently  made.  Choked 
disk  is  uncommon,  there  being  rather  a  primary  atrophy  of  the  nerve. 
The  involvement  of  other  cranial  nerves  is  fairly  common.  In  207 
acromegalic  cases  Uhthoff  found  exophthalmos  in  8  per  cent.;  muscle 
palsies  in  10  per  cent.  The  third  nerve  was  involved  in  23  cases,  the 
sixth  in  four  cases.  In  a  series  of  121  patients  with  tumor  and  without 
acromegaly,  25  per  cent,  showed  muscle  palsies;  third  nerve,  twenty- 
six  times;  sixth  nerve,  seven  times. 


Fig.  102. — A'-ray  photograph  of  sella  in  case  shown  in  Pig.  62.  Note  the  absence  of 
a  posterior  clinoid  process.  This  observation  led  to  a  diagnosis  of  erosion  by  malignant 
growth.  The  autopsy  showed  that  while  the  growth  was  malignant  there  was  no 
erosion,  the  absence  of  the  process  being  apparently  congenital. 

Pressure  upon  the  cerebral  peduncles  will  later  cause  accentuated 
knee-jerks  and  finally  even  more  serious  sjonptoms.  This  may  follow 
from  direct  growth  extending  downward  or,  as  in  one  of  my  cases,  the 
tumor  may  invade  the  third  ventricle  and  cause  similar  signs. 

Pressure  upon  the  uncinate  process  of  the  hippocampal  gyrus  may 
produce  epileptiform  seizures  preceded  by  gustatory  and  olfactory 
sensations  and  a  dreamy  state. 

Pressure  upon  the  frontal  lobes  may  be  the  possible  cause  of  the 
mental  deterioration  seen  in  many  cases. 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN        347 

Evidences  of  general  brain  pressure  may  supervene  at  any  time,  due 
to  hemorrhage  into  cysts,  to  the  growth  of  the  tumor  outside  of  the 
sella,  or  consequent  ventricular  hydrops. 


Fig.  103. — Brain  and  sella  of  patient  presenting  evidences  of  hjTDopituitarism.  Exces- 
sive fat,  little  hair,  etc.  Patient  died  after  two  years!  observation.  Temporarj'  relief 
was  secured  by  corpus  callosum  puncture,  subtemporal  decompression  having  been  of 
little  value.  Postmortem  showed  no  tumor  mass,  but  internal  hydrocephalus,  probably 
of  inflammatory  origin.     (Wesley  Memorial  Hospital,  No.  50909.) 


Pineal  Gland. — Bailey  and  JellifPe  have  collected  the  reports  of 
these  rare  tumors  and  classified  the  sjTaptoms.  The  general  sjTnptoms 
of  pressure  are  commonly  present  and  the  focal  evidences  are  found  in 
two  groups :  (a)  the  neurologic,  (6)  the  metabolic. 

TJie  Neurologic. — These  cases  show  not  alone  the  evidences  of 
general  brain  pressure  and  hydrocephalus,  but  also  those  findings 
peculiar  especially  to  third  ventricular  dilatation,  perversion  of  pos- 
terior lobe  hA,"pophyseal  secretion,  v.  s.  Pressure  upon  the  corpora 
quadrigemina  gives  ocular  and  pupillary  signs.  Isolated  ner^ie  palsies 
are  common.  '  Nystagmus  is  not  infrequent.  Cerebellar  symptoms 
arise  from  pressure  upon  the  peduncles. 

The  Metabolic. — We  commonly  see  adiposis,  early  sexual  maturity 
and  cachexia.  Whether  the  adiposis  is  due  to  pineal  perversion  or  to 
distention  of  the  third  ventricle  and  pressure  with  non-absorption  from 
the  posterior  lobe  of  the  pituitary  gland  may  be  open  to  discussion,  but 
its  presence  is  fairly  common. 

Gutzeit  first  drew  attention  to  the  early  development  of  sexual 
characteristics  with  enlargement  of  the  penis,  general  hypertrichosis, 
increased  libido,  and  at  times  change  of  voice.  Here,  again,  we  do  not 
know  whether  this  is  due  to  the  inherent  physiology  of  the  pineal  gland, 
to  pressure,  or  to  an  irritation  of  the  neighboring  structures. 


348     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

Visual  Reflexes. — If  we  follow  the  optic  nerves  back  from  the 
eyeballs,  we  find  that  the  nerves  meet  at  the  base  of  the  brain  and  form 
the  optic  chiasm  where  a  decussation  takes  place;  the  fibers  from  the 
temporal  halves  of  the  retina  passing  backward  on  the  same  side,  and 
the  fibers  from  the  nasal  haves  crossing  to  the  opposite  side  uniting 
with  the  opposite  temporal  fibers  forming  the  optic  tracts.  Central 
fibers  from  the  macula  lutea  pass  into  both  optic  tracts.  These  tracts 
wind  around  the  crus  cerebri  to  the  primary  optic  centers,  the  external 
geniculate  body,  the  anterior  corpora  quadrigemina,  and  the  pulvinar 
of  the  optic  thalamus.  There  arise  also  commissural  fibers  which  pass 
forward  and  cross  in  the  optic  chiasm  connecting  the  two  internal 
geniculate  bodies. 

It  is  believed  that  the  optic  thalamus  and  the  external  geniculate 
body  have  to  do  with  the  reception  of  visual  impulses  and  the  forward- 
ing of  these  to  the  cerebral  cortex,  while  the  anterior  corpora  quadri- 
gemina are  mainly  concerned  with  the  coordination  of  visual  impulses 
and  visual  movements,  and  movements  especially  relating  to  the  laby- 
rinth and  cerebellum.  This  is  corroborated  by  experimental  evidence 
in  that  stimulation  of  these  bodies  excites  movements  of  the  eyes  and 
head  and  extirpation  interferes  with  coordination  but  not  with  sight. 
Fibers  arise  from  the  optic  thalamus  and  the  external  geniculate  body 
and  possibly  also  from  the  anterior  corpora  quadrigemina  and  pass 
backward  through  the  hinder  end  of  the  posterior  limb  of  the  internal 
capsule  to  form  the  optic  radiation  and  be  distributed  to  the  occipital 
lobes.  The  center  in  the  occipital  lobe  is  mainly,  but  not  entirely,  on 
the  mesial  aspect  of  the  hemisphere  and  is  divided  into  an  upper  and  a 
lower  part  by  the  calcarine  fissure,  the  cuneate  lobe  lying  above  and 
the  lingual  gyrus  below.  These  two  parts  represent  quadrants  of  the 
corresponding  half  of  the  visual  field;  e.  g.,  a  lesion  of  the  left  cuneus 
will  cause  blindness  of  the  right  lower  quadrant  of  both  visual  fields. 
Besides  these  centers,  there  is  a  higher  center  on  the  convex  surface  of 
the  occipital  lobe  where  a  superficial  lesion  will  cause  not  hemianopsia 
but  crossed  amblyopia,  i.  e.,  a  concentric  contraction  of  both  visual 
fields,  more  marked  in  the  opposite  eye.  Also  in  right-handed  people, 
there  is  in  the  left  angular  g^Tus  a  center  for  the  storage  of  visual 
memories  of  written  and  printed  words,  destruction  of  which  produces 
word  blindness  (Stewart).  The  diagrammatic  representation  after 
Vialet  (Plate  III)  shows  the  various  types  of  blindness  produced  by 
lesions  of  given  parts  of  the  nerve  and  tracts.  In  addition  to  the  co5rdi- 
nated  movements  governed  by  the  anterior  corpora  quadrigemina,  the 
centers  for  eye  movements  are  found  in  the  centers  of  the  nerves, 
third  and  others,  lying  in  the  floor  of  the  iter  and  the  third  ventricle. 
Stimulation  of  the  back  part  of  the  third  ventricle  causes  contraction 
of  the  pupil ;  of  the  corpora  quadrigemina,  dilatation :  while  stimulation 
along  the  floor  of  the  iter  produces  contraction  of  the  various  eye 
muscles.  Certain  movements  of  the  eye  may  also  be  produced  by 
stimulation  of  the  surface  of  the  occipital  lobe  in  the  eye  centers,  a 
result  brought  about  possibly  through  association  fibers. 


PLATE    in 


Cuneus 


CCj^4t 


.t^TTOcp 


Optic  Radiations  ^ 


Corpus  Callosum 


Optic  Thalamus-/—. 


Corp.  genie,  ext 


Optic  Tract-'- 


Optic  Nerve 


Diagram  after  Vialet,  Showing   Various   Types  of 
Blindness. 

1,  Blindness  of  One  Kye;  2,  Bitemporal  Hemianopia;  3  Binasal 
Hemianopia;  4,  Right  Hem>anopia  with  Hemiopie  PupU  Reaction- 
S  and  6,  Right  Hemianopia  with  Normal  Pupil  Reaction;  7,  Crossed 
Amblyopia.  v^^^c-i 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN        349 

Relation  of  the  Ear  to  Tumors  and  Abscesses  of  the  Brain. — I  am 

indebted  to  Dr.  J.  Gordon  Wilson  for  the  following  discussion  of  the 
relation  of  the  ear  to  tumors  and  abscesses  of  the  brain. 

The  chief  symptoms  of  lesions  of  the  membranous  labyrinth  of  the 
ear  (including  the  VIII  nerve)  are  deafness,  tinnitus,  vertigo,  nys- 
tagmus and  ataxia,  with  nausea  and  vomiting.  These  symptoms  also 
may  occur  in  lesions  of  the  brain  and  so  a  differential  diagnosis  fre- 
quently has  to  be  made.  When  the  lesion  is  confined  to  the  ear  the 
diagnosis  is  as  a  rule  easy.  When  the  VIII  nerve  is  involved  directly, 
for  instance,  by  pressure  of  a  tumor  in  the  internal  auditory  meatus, 
the  diagnosis  may  be  more  difficult.  When  the  lesion  involves  the 
labyrinth  and  a  lesion  secondary  to  it  in  some  part  of  the  cranium, 
e.  g.,  an  abscess,  the  location  of  the  abscess  may  involve  considerable 
difficulty.  Yet  there  are  certain  broad  lines  which  taken  together 
offer  a  basis  for  an  accurate  diagnosis.  The  history  of  the  case  and  the 
involvement  of  other  cranial  nerves  should  those  be  present  are  of 
very  material  assistance. 

Deafness. — Deafness  may  occur  not  only  from  involvement  of  the 
termination  of  the  auditory  nerve  in  the  labyrinth  and  its  central 
connections  but  also  from  disease  in  the  conducting  mechanism  in  the 
external  meatus  and  middle  ear.  This  preliminary  separation  of  deaf- 
ness due  to  disease  in  the  conducting  mechanism  from  nerve  deafness 
is  made  by  tests  well  known  to  otologists  but  because  of  the  frequency 
with  which  both  are  involved  no  hard  and  fast  distinction  can  always 
be  made.  When  we  try  to  locate  the  defect  in  hearing  in  some  part  of 
the  nerve  or  of  its  central  connections  we  are  met  with  great  obstacles 
unless  we  are  aided  by  some  concomitant  symptom  such  as  pressure 
on  the  seventh  nerve,  involvement  of  the  vestibular  mechanism,  etc. 

Nerve  deafness  may  occur  from  a  lesion  in  the  cochlear  branch  of  the 
eighth  nerve  or  in  its  central  connections.  A  gross  lesion  of  the  eighth 
nerve  previous  to  entering  the  brain  will  almost  certainly  involve  the 
vestibular  branch  of  the  eighth  and  very  often  the  seventh  cranial 
nerve.  As  the  cochlear  nerve  decussates  early  and  is  widely  distributed 
a  lesion  of  the  brain  resulting  in  total  deafness  will  rarely  occur  unless 
we  have  a  very  considerable  lesion.  Thus  deafness  may  be  due  to  dis- 
ease in  the  temporal  lobes  but  can  only  be  considerable  if  the  auditory 
sphere  of  both  sides  be  involved.  In  short,  deafness  is  often  difficult 
to  definitely  locate  and  so  it  becomes  only  an  important  accessory  in 
locating  a  lesion. 

Tinnitus. — ^Tinnitus  the  sensation  of  noises  in  ear  or  head,  is  a  fre- 
quent symptom  of  all  forms  of  aural  complications.  Tinnitus  may  not 
cease  after  destruction  of  the  labyrinth  or  section  of  the  eighth  nerve. 
It  is  difficult  to  estimate  because  its  phenomena  are  purely  subjective. 
It  has  little  diagnostic  value  unless  it  be  directly  related  in  its  time  of 
appearance  and  in  its  intensity  to  a  cranial  lesion. 

In  disturbances  of  the  vestibular  mechanism — ^nystagmus,  vertigo 
and  ataxia — we  have  symptoms  that  lend  themselves  more  definitely 
to  observation  and  to  estimation.    As  these  three  symptoms  are  fre- 


350     TUMORS,   IXFLAMMATIONS  AXD  ABSCESSES  OF  BRAIN 

quent  in  eerebellar  disease  and  as  it  is  from  lesions  of  the  cerebellum 
that  one  has  most  commonly  to  separate  lab^Tinthine  disease,  we  may 
confine  our  observations  chiefly  to  the  differential  significaace  of  these 
s\Tnptoms  in  lab^Tinthine  and  in  cerebellar  lesions.  It  may  here  be 
noted  that  a  slowly  progressing  disease  of  the  vestibular  mechanism 
may  present  no  s^^nptoms;  and  in  the  diagnosis  the  otologist  may  have 
to  depend  on  tests  for  the  physiological  activity  of  the  labyrinth,  e.  g., 
the  caloric  and  rotation  tests.  A  sudden  onset  or  marked  acceleration 
of  vestibular  disease  always  is  accompanied  by  the  above  symp- 
toms. 

Nystagmus. — Nystagmus  or  oscillation  of  the  eyes  occurs  in  various 
diseases  of  the  brain,  e.  g.,  in  tumors  of  the  posterior  corpora  quad- 
rigemina  and  cerebellum ;  also  in  peripheral  eye  lesions  and  in  labyrinth 
diseases.  In  a  considerable  number  of  normal  individuals  a  slight 
spontaneous  nystagmus  is  present  in  extreme  lateral  position  of  the 
eyes  and  has  no  pathological  significance.  Marked  spontaneous 
nystagmus  on  looking  to  the  side  and  even  slight  nystagmus  on  looking 
straight  forward  is  pathological. 

Nystagmus  occurring  in  a  labATinthine  lesion  consists  of  two  phases: 
a  slow  lateral  deviation,  labjTinthine  in  origin,  followed  by  a  quick 
return  movement,  cerebral  in  origin,  sjTichronous  in  both  eyes.  It  is 
decreased  or  even  arrested  by  looking  in  the  directions  of  the  slow 
phase,  it  is  increased  by  looking  in  the  direction  of  the  quick  phase. 
By  the  use  of  suitable  lenses  which  reduce  or  eliminate  fixation,  laby- 
rinthine nystagmus  is  increased  or  even  made  to  appear.  The  only 
cranial  lesion  that  gives  an  identical  picture  is  one  involving  the  central 
connection  of  the  vestibular  branch  of  the  eighth  nerve,  to  the  eye  nuclei, 
for  instance,  a  lesion  of  Deiter's  nucleus  and  of  the  posterior  longi- 
tudinal bundle.  The  slow  phase  in  lab\Tinthine  lesions  is  toward  the 
side  of  the  lesion.  Exceptions  to  this  rule  may  arise  from  irritation 
(not  paralysis)  of  the  vestibular  nerve  somewhere  in  its  central  course. 
So  far  as  the  otologist  is  concerned,  dealing  v\^ith  the  terminal  organ,  it 
only  arises  in  connection  with  a  well  marked  inflammatory  lesion  in 
the  ear  involving  the  petrous  temporal  bone  and  the  vestibular  nerve. 
In  lab^Tinthine  lesions  the  nystagmus  with  the  slow  phase  to  the  side 
of  the  lesion  varies  in  intensity  during  the  firsf  few  days  then  gradually 
diminishes.  If  it  persists  unaltered  for  several  days  it  points  to  involve- 
ment of  the  vestibular  nerve. 

Cerebellar  nystagmus  consists  of  mo^'ements  which  are  ataxic  in 
character.  With  the  eyes  at  rest  it  tends  to  lessen  or  disappear  but  is 
increased  by  fixation.  The  plane  in  which  the  nystagmus  moves  as 
well  as  its  intensity  varies  from  time  to  time.  It  also  frequently  shows 
a  slow  and  quick  phase — the  slow  phase  may  be  away  from  the  side 
of  the  lesion  or  toward  it,  according  to  whether  we  are  dealing  with  an 
irritative  or  a  destructive  lesion. 

In  short,  lab\Tinthine  and  cerebellar  nystagmus  differs  in  uniformity 
of  direction  and  in  character.  Not  all  cerebellar  lesions  produce  nys- 
tagmus and,  further,  it  is  possible  for  a  cerebellar  tumor  to  produce  the 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN        351 

labyrinthine  t}^e  by  pressure  on  the  vestibular  nerve  or  the  vestibular 
path  in  the  pons. 

Vertigo. — ^Vertigo  is  one  of  the  most  general  symptoms  of  brain  dis- 
ease. The  little  appreciation  of  its  value  in  diagnosis  may  be  due  to  a 
failure  to  appreciate  its  significance  and  the  wide  application  of  the 
term  to  symptoms  of  very  different  kinds.  It  is  applied  to  a  variety 
of  subjective  sensations  and  even  from  intelligent  patients  it  is  very 
difficult  to  get  a  clear  account  of  these  sensations.  The  more  severe 
symptoms  of  vertigo  are  associated  with  disease  of  the  labyrinth  and 
its  vestibular  nerve;  and  of  the  cerebellum  with  its  peduncles.  These 
are  frequently  associated  with  objective  symptoms  of  vertigo,  insta- 
bility, falling,  etc.  The  most  distinctive  subjective  sensation  which 
the  patient  complains  of  is  the  apparent  rotation  of  himself  or  of 
external  objects.  In  lab^Tinthine  disease  the  apparent  rotation  is 
directly  related  to  the  nystagmus,  it  is  in  the  direction  of  the  quick 
phase  and  the  direction  of  falling  is  in  the  direction  of  the  slow  phase. 
There  is  not  the  same  uniformity  in  cerebellar  disease  and  the  rules 
suggested  by  Stewart  and  Holmes  are  only  to  be  regarded  as  valuable 
suggestions.  Attacks  of  vertigo  with  its  objective  s\Tnptoms  caused 
by  labyrinthine  lesions  gradually  disappear  as  the  acute  attack  passes 
off.  In  neurasthenia  they  may  persist  for  a  long  time  but  gradually 
lose  their  distinctive  labjTinthine  character. 

Disorientation  and  Ataxia. — In  both  cerebellar  and  labjTinth  lesion 
there  is  a  deviation  in  walking  toward  one  side — to  the  side  of  the  lesion 
if  unilateral.  This  the  patient  corrects  when  the  eyes  are  open.  But 
with  the  eyes  shut,  when  the  patient  recognizes  the  deviation  he  may 
deviate  to  the  other  side.  Especially  in  cerebellar  cases  he  is  very  apt 
to  overcorrect.  Romberg's  sign  is  present  in  labjTinthine  disease.  It 
is  rare  in  atrophy  and  sclerosis  of  the  cerebellum;  it  is  frequent  in 
abscesses,  tumors  or  lesions  which  from  their  nature  are  prone  to  affect 
other  structures.  In  labyrinthine  lesions  in  the  Romberg  position  the 
patient  falls  in  the  direction  of  the  slow  phase  of  the  nystagmus  and 
if  the.  head  be  turned  he  will  fall  backward  or  forward  but  still  in  the 
direction  of  the  slow  phase.  This  relation  of  falling  to  position  of  the 
head  does  not  exist  in  cerebellar  disease. 

Dysmetria. — Dysmetria  is  not  present  in  labyrinth  disease.  The 
muscular  failure  in  labyrinthine  cases  is  due  to  a  failure  of  accurate 
perception  of  changes  of  the  head  in  space  resulting  in  a  maladjustment 
of  muscles  to  maintain  equilibrium  and  direct  orientation.  The  drunken 
gait  of  the  cerebellar  patient  is  not  pronounced  in  lab;sTin thine  disease. 

In  addition  the  otologist  has  at  his  disposal  direct  functional  tests 
for  lab}Tinth  activity  in  the  rotation  test  and  the  caloric  reaction  which 
afford  information  in  regard  to  the  physiological  activity  of  the  laby- 
rinth. A  discussion  of  these  is  not  called  for  here.  The  above  account 
is  necessarily  brief.  Little  has  been  said  of  those  complex  cases  which 
involve  both  the  eighth  nerve  and  the  cerebellum.  Detailed  informa- 
tion in  regard  to  such  cases  and  to  functional  testing  must  be  sought 
for  in  the  numerous  articles  available. 


352     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

Conjugate  deviation  of  the  eyes  and  head  toward  the  same  side  is 
found  in  disease  of  the  cerebrum  which  commences  with  paralysis  of 
the  opposite  side  of  the  body,  in  which  case,  especially  at  the  onset, 
the  head  and  eyes  are  often  deviated  toward  the  side  of  the  lesion; 
i.  e.,  away  from  the  paralyzed  side.  In  spasmodic  conditions  the  devia- 
tion is  toward  the  same  side.  The  sign  is  seen  especially  in  lesions  of 
the  first  and  second  frontal  convolutions,  but  may  be  seen  elsewhere 
(e.  g.,  angular  gATUs,  occipital  lobe,  etc.).  In  pontine  disease  the  eyes 
deviate  toward  the  same  side  as  the  paralysis,  due  probably  to  involve- 
ment of  the  crossed  posterior  longitudinal  bundle. 

Another  important  finding  is  that  of  astereognosis,  i.  e.,  the  loss  of 
the  power  to  recognize  the  form  and  shape  of  objects  by  palpation. 
This  condition  may  be  due  to  tactile  anesthesia,  but  generally  represents 
a  combined  psychophysical  act,  in  which  association  fibers  come  into 
play.  Astereognosis  may  be  due,  therefore,  to  lesions  of  the  post- 
central convolutions,  to  lesions  behind  it  (Wernicke),  or  to  lesions  in 
the  parietal  lobe  (Oppenheim,  Bruns,  Mills,  etc.). 

General  Symptoms  and  Signs  of  Brain  Tumor. — These  are  due  to 
an  increase  in  intracranial  tension,  produced  both  by  the  growth  of  the 
tumor  and  the  improper  circulation  or  increase  of  the  cerebrospinal 
fluid.  The  most  important  of  these  are:  choked  disk,  headache,  and 
vomiting ;  and  to  these  must  be  added  slow  pulse,  vertigo,  stupor,  and 
convulsions.  It  should  be  remembered  that  the  triad  may  be  produced 
by  nepliritis,  severe  anemia,  lead  poisoning,  and  less  frequently  by 
other  causes. 

Choked  Disk. — This  is  found  in  90  per  cent,  of  the  brain  tumors  at 
some  time  in  their  course.  Early  transient  dimness  of  vision  is  common, 
and  a  certain  degree  may  be  present  with  perfect  vision.  Frequently 
the  congestion  is  greater  upon  the  affected  side,  although  both  eyes 
are  generally  involved.  In  cerebellar  tumors,  choked  disk  is  especially 
early  in  onset,  due  to  overfilling  of  the  ventricles  with  fluid.  The 
choked  disk  is  followed  in  time  by  atrophy  with  its  persistent  blindness 
although  one  may  regain  a  certain  amount  of  vision  in  almost  hopeless 
cases  if  some  vision  is  still  present.  In  tumors  pressing  directly  upon 
the  nerves,  the  atrophy  may  progress  without  noticeable  congestion 
at  any  time.  This  is  seen  particularly  in  hypophyseal  tiunors.  Gushing 
has  laid  particular  stress  upon  the  interlacing  of  the  color  fields,  saying 
that  it  is  present  in  40  per  cent,  of  the  cases.  This  has  not,  however, 
been  of  much  diagnostic  importance  in  the  experience  of  the  author. 

Headache. — This  is  the  most  constant  symptom,  and  is  often  of 
great  severity,  consisting  of  a  constant  dull  ache,  accompanied  by 
exacerbations.  This  latter  is  an  important  observation,  since  the 
former  may  be  due  to  many  causes.  The  patient  is  little  relieved  by 
treatment.  The  headache  is  generally  diffuse,  but  may  localize, 
although  localization  is  not  diagnostic  except  where  the  tumor  is  near 
the  surface  and  the  localized  headache  is  accompanied  by  localized 
tenderness  of  the  skull,  and  even  in  such  instances  it  may  lead  to  error; 
cerebellar  tumors  may  produce  frontal  headache.     Anything  that 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN         353 

increases  cerebral  hyperemia,  e.  g.,  exertion,  excitement,  coughing, 
will  increase  the  headache.  Von  Bruns  has  noted  that  tumors  of  the 
posterior  fossa  produce  morning  headache  due  in  his  opinion  to  the 
congestion  incident  to  the  recumbent  position.  If  the  headache  in  the 
back  of  the  head  is  accompanied  by  stiffness  of  the  neck  muscles,  it 
speaks  somewhat  for  a  tumor  there. 

Vomiting. — This  is  not  constant,  but  is  present  in  a  majority  of  cases, 
and  is  most  constant  in  cerebellar  tumors.  It  follows  the  headache  and 
is  often  projectile  in  character,  and  may  or  may  not  be  accompanied 
by  nausea,  occurring  independently  of  the  taking  of  food  and  without 
relation  to  gastro-intestinal  disorders. 

Slow  Pulse. — This  is  a  valuable  sign  when  present.  It  may  be 
transient  or  permanent,  and  is  usually  a  late  sign.  It  falls  to  48  or  less 
and  may  be  accompanied  by  Cheyne-Stokes  breathing,  yawning,  and 
hiccough. 

Stupor. — This  may  be  preceded  by  a  progressive  mental  change. 
The  patient  is  apathetic,  answers  question  slowly,  and  finally  passes 
into  a  stupor  in  which  he  may  lose  control  of  the  bladder  and  rectum. 

Vertigo. — One  finds  vertigo  most  commonly  associated  with  tumors 
involving  the  cerebellum,  cerebellar  peduncles  and  the  corpora  quad- 
rigemina,  but  it  is  associated  with  certain  other  basal  tumors  involving 
these  areas  secondarily  and  the  vestibular  nerve  or  its  ganglia.  Bruns 
has  noted  its  presence  in  cysticercus  of  the  fourth  ventricle.  The 
vertigo  is  more  often  a  confusion  such  as  is  seen  in  intoxication;  real 
giddiness  and  falling  down  is  less  common.  It  is  seen  at  times  asso- 
ciated with  paresis  of  the  eye  muscles,  due  to  close  association  of  their 
centers  with  Deiter's  nuclei.  A  more  detailed  discussion  of  its  relation 
to  cerebellar  disease  and  otitic  processes  will  be  found  in  the  sections 
dealing  with  these  diseases. 

Convulsions. — We  distinguish  here  the  Jacksonian  type  due  to 
primary  involvement  of  the  motor  area.  As  a  sign  of  general  increase 
of  intracranial  tension,  they  appear  late,  although  they  may  be  the 
earliest  evidence,  and  one  must  wait  for  choked  disk  and  other  evidences 
of  tumor  before  idiopathic  epilepsy  can  be  excluded.  They  are  seldom 
of  localizing  value. 

Diabetes,  polyuria,  polydipsia,  genital  changes,  adiposity,  etc.,  may 
be  seen,  but  are  to  be  considered  rather  under  local  signs.  Auscul- 
tatory changes — the  cracked  pot  in  fractures  or  in  the  skull  which  has 
separated  along  the  fissures,  and  bruit  in  aneurysms  may  be  heard; 
indeed,  the  bruit  may  be  heard  in  other  conditions;  e.  g.,  in  infants  and 
where  the  vessels  are  compressed  by  a  tumor.  It  may  be  heard  only 
by  the  patient  as  a  subjective  sensation.  Tympany  on  percussion  may 
be  noted  where  the  skull  is  much  thinned. 

The  differential  diagnosis  must  take  into  consideration  the  many 
diseases  that  will  produce  the  general  sign  of  tumor,  e.  g.,  nephritis, 
lead  poisoning,  multiple  sclerosis,  epilepsy,  paretic  dementia,  abscess, 
gummata,  and  finally  the  so-called  pseudo-tumor,  in  which  little  or  no 
pathology  may  be  found  at  postmortem.    At  times  an  acute  hydro- 

VOL.  I — -23 


354     TUMORS,   IXFLAMMATIOXS  AXD  ABSCESSES  OF  BRAIN 

cephalus  may  be  seen  that  may  he  ^eUe^■ed  hy  himhar  puncture  or  a 
localized  ependymitis  of  the  Sylvian  aqueduct  with  resulting  distention 
of  the  ventricles. 

It  should  be  remembered  that  gummata  may  resist  sj'philitic  treat- 
ment. Sudden  apoplectiform  seizures  in  the  course  of  cranial  disease 
may  be  seen  in  gliomata.  It  has  happened  to  the  author  to  operate 
upon  one  case  while  the  hemorrhage  was  active  and  the  preoperative 
diagnosis  was  made  because  of  the  complication. 

Abscesses  generally  give  a  history  of  some  possible  primary  source 
and  in  the  acuter  forms  we  have  a  leukocytosis.  Tubercles  frequently 
occm-  at  the  cerebellopontine  angle  and  adjacent  areas.  Gliomata 
originate  in  the  brain  and  do  not  involve  the  meninges  or  bone  while 
the  sarcomata  originate  in  the  meninges  or  bone  and  compress  or 
in^•olve  the  brain-tissue.  The  gummata  and  tubercles  may  resemble 
each  other  on  superficial  examination  and  a  microscopic  examination 
be  necessary  to  differentiate  them.  Gliomata  appear  especially  in 
order  of  frequency  in  the  hemispheres  of  the  cerebrum,  cerebellum,  and 
pons;  the  solitary  tubercles  in  the  pons,  cerebellum,  or  cerebral  cortex; 
the  gummata  generalh'  in  the  cerebrum;  sarcoma  in  the  meninges, 
bones  of  the  base,  parietal  and  sphenoid  especially.  The  gliomata 
grow  slowly  and  the  sarcomata  rapidly.  Gummata  have  rapid  growth 
and  sudden  recession.  The  gliomata  and  sarcomata  are  single  and  the 
tubercles  and  gummata  may  be  multiple. 

Cysts  may  occiu-  as  a  result  of  parasitic  growth  (echinococcus  or 
cysticercus)  or  trauma.  The  first  will  have  the  history  of  the  disease 
in  some  other  part  of  the  body,  and  the  latter  a  history  of  injury.  At 
times  they  ha\'e  origin  in  a  hemorrhage  into  a  glioma.  Von  Bruns  has 
studied  particularly  the  occiu'rence  and  signs  of  cysticercus  in  the 
fourth  ventricle. 

Carcinoma  is  generally  secondary  but  may  occur  in  connection  with 
the  choroid  plexus.  Cholesteatoma,  psammoma,  fibroma,  and  lipoma, 
are  uncommon.  Endotheliomata  are  fairly  common,  developing  from 
about  the  vessels  of  the  meninges. 

Lumbar  Puncture  and  the  Cerebrospinal  Fluid. — As  a  means  of 
diagnosis  an  examination  of  the  cerebrospinal  fluid  is  of  considerable 
importance.  Unfortunately,  the  findings  are  not  pathognomic,  but 
must  be  correlated  with  the  clinical  data.  Therefore,  a  just  apprecia- 
tion of  the  value  comes  only  after  considerable  bedside  experience. 
We  cannot  expect  the  laborators'  to  report  that  this  or  that  patient 
has  a  gumma,  tumor,  or  meningitis. 

There  is  some  therapeutic  value  to  puncture  in  certain  t^^Dcs  of 
brain  pressure,  unfortunately  generally  transitory,  although  in  my 
experience  certain  cases  of  vertigo  and  tinnitus  have  been  relieved 
over  a  considerable  period. 

Some  danger  is  to  be  feared  in  tumors  so  located  as  to  impinge  on 
the  cord  or  medulla  at  the  foramen  magnum,  since  the  latter  may  be 
compressed  and  cause  sudden  death.  Where  there  is  cause  to  fear  this, 
and  indeed,  in  all  brain  tumors,  it  is  advisable  to  withdraw  fluid  slowly, 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN        355 

and  to  place  the  patient  with  the  head  lower  than  the  body.  The  pos- 
sibility of  infection  is  slight  if  care  is  taken,  and  the  same  may  be 
said  of  injury  to  nerves.  It  is  advisable  to  have  the  patient  rest  for 
twenty-four  hours  after  the  puncture,  especially  if  headache  develops. 
Where  a  small  amount  of  fluid  is  withdrawn  this  is  not  necessary.  Ten 
cubic  centimeters  may  be  removed  without  anxiety,  and  I  have  often 
taken  forty  slowly,  without  injury.    The  fluid  is  rapidly  replaced. 

Technic. — The  skin  is  sterilized  and  cocainized,  and  the  patient 
placed  preferably  upon  the  side  with  the  back  bent,  the  thighs  flexed 
up  toward  the  flexed  head.  If  brain  tumor  is  not  suspected,  a  sitting 
posture  renders  the  operation  less  difficult.  The  point  of  choice  for 
puncture  is  between  the  third  and  fourth,  or  better,  the  fourth  and 
fifth  lumbar  vertebrae,  determined  by  drawing  a  line  between  the  crests 
of  the  ilia.  A  small  sharp,  unrusted  needle,  the  lumen  of  which  has 
been  tested,  about  8  cm.  long,  is  chosen.  The  surgeon  places  the  ball 
of  the  thumb  upon  the  spine  of  the  fourth  lumbar  vertebra  and  at  the 
lower  and  outer  angle;  i.  e.,  one-half  inch  outside  and  below  the  spine, 
the  needle  is  inserted  upward  and  inward  at  such  an  angle  as  to  reach 
the  center  at  a  depth  of  about  two  and  a  half  inches.  Here  the  needle 
strikes  the  ligamentum  subflavum  between  the  vertebrae.  This  slight 
resistance  is  overcome  and  the  needle  immediately  enters  the  sub- 
arachnoid space  and  the  spinal  fluid  begins  to  drop  out.  If  we  strike  a 
lamina,  the  needle  is  withdrawn  slightly  and  inserted  above  or  below. 
After  feeling  the  sudden  penetration  through  the  ligamentum  sub- 
flavum, if  the  fluid  does  not  flow,  a  stylette  is  passed  to  clear  the  lumen 
of  any  clot  of  blood  or  push  away  a  nerve  that  may  be  blocking  the 
needle.  If  no  fluid  escapes,  we  may  puncture  at  the  next  space  above. 
The  procedure  should  be  carried  out  with  as  little  trauma  as  possible, 
since  the  presence  of  blood  interferes  with  our  tests.  If  some  blood 
does  appear,  it  may  be  clear  after  a  few  drops.  If  it  does  not  become 
clear,  a  second  puncture  should  be  made  higher  up,  since  a  delay  until 
another  day  may  result  in  slight  local  inflammation  that  will  also 
impair  the  accuracy  of  our  findings.  Indeed,  some  days  must  elapse 
before  we  are  sure  of  securing  a  clear  fluid. 

The  cerebrospinal  fluid  is  absolutely  clear,  colorless,  and  of  a 
specific  gravity  of  1005  to  1008.  It  is  alkaline  and  contains  a  trace  of 
serumglobulin  and  albumose  and  also  will  reduce  Fehling's  solution. 
Microscopically  a  few  large  endothelial  plates  will  be  seen  and  in  the 
centrifuged  specimen  a  few  lymphocytes,  three  to  five  to  the  cubic 
centimeter.  The  presence  of  blood  in  the  serum  impairs  the  value  of 
the  microscopic  and  chemical  tests. 

The  pressure  of  the  fluid  should  be  noted.  This  can  be  approximated 
clinically  by  always  using  in  our  puncture  the  same  size  of  needle  and 
placing  the  patient  in  the  same  position.  We  may  measure  it  by 
attaching  a  rubber  tube  and  a  manometer  to  the  needle. 

The  color  and  clarity  are  important  findings.  If  blood  be  present 
it  may  come  from  the  local  trauma  or  a  skull  fracture  or  subarachnoid 
hemorrhage.    If  the  blood  is  from  a  preexisting  subarachnoid  hemor- 


356     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

rhage,  cerebral  or  spinal,  we  may  determine  this  at  times  by  centri- 
fuging,  since  a  fluid  will  remain  yellowish  and  not  present  the  clear 
limpid  serum  characteristically  found  when  freshly  mixed  blood  and 
serum  are  treated  similarly.  It  may  be  turbid  or  purulent  from  acute 
meningitis. 

Microscopic  examination  reveals  the  presence  of  lymphocytes,  poly- 
morphonuclear leukocytes,  blood,  and  bacteria.  The  number  per 
cubic  millimeter  and  character  of  the  cells  should  be  noted. 

The  cJiemical  characteristics  have  been  extensively  studied.  An 
mcreased  serum  albumin  content  may  suggest  spinal  tumor,  meningitis, 
etc.  Various  tests  for  the  globulin  have  been  devised,  such  as  the 
Noguchi  butyric  acid  or  the  Nonne  ammonium  sulphate,  Lange's 
colloidal  gold  reaction,  the  Ross-Jones  ammonium  sulphate  tests. 

Wassermann  reaction  for  syphilis  may  show  in  the  fluid  when  it  is 
not  evident  in  the  blood. 

The  clinical  deductions  of  the  tests  are,  as  noted  above,  relative 
rather  than  absolute.  In  general  it  may  be  said  that  slowly  growing, 
chronic  meningeal  inflammations  due  to  various  causes  and  tuber- 
culosis and  s}T)hilis  will  produce  excessive  globulin  and  an  increase  of 
lymphocytosis,  while  the  more  acute  inflammations  give  rise  to  poly- 
morphonuclear deposits  and  excessive  globulin.  Varying  with  the 
severity  and  stage  in  any  individual  disease,  the  picture  may  be  different. 
Tuberculous  meningitis  shows  a  high  lymphocytosis,  even  running 
into  the  hundreds  per  cubic  millimeter.  The  polynuclear  element  may 
be  marked  in  the  acute  cases.  Fehling's  solution  may  or  may  not  be 
reduced.  There  is  a  positive  globulin  reaction,  but  the  fluid  is  generally 
not  turbid  as  in  acute  meningitis.  Careful  examination  of  the  coagulum 
that  settles  out  after  some  hours  will  frequently  show  tubercle  bacilli. 
Acute  meningitis  shows  a  turbid  fluid  with  many  polynuclear 
leukocytes,  some  lymphocytes,  globulin,  lack  of  Fehling  reduction, 
and  the  typical  organisms. 

S3T)hilis  presents' a  varied  picture,  corresponding  to  the  stage  of  the 
disease:  the  more  acute  processes  presenting  the  leukocytes  and  lym- 
phocytes, globular  reaction,  and  a  Wassermann  reaction.  As  the 
disease  progresses  to  the  stage  of  tabes  and  such  chronic  conditions, 
the  leukocytes  decrease,  the  lymphocytes  increase  and  then  decrease, 
the  globulin  ultimately  disappears,  and  the  Wassermann  cannot  be 
obtained. 

Brain  tumors  may  produce  no  changes  in  the  fluid,  but  in  certain 
cases  where  the  meninges  are  irritated,  e.  g.,  cerebellopontine  tumors, 
the  cell  count  may  be  increased  and  the  globulin  tests  be  positive. 

Radiology  in  Brain  Tumors  and  Abscesses. — ^In  tumors  of  the 
hypophysis,  in  abscesses  following  destruction  of  the  mastoid,  and  in 
calcified  tumors,  the  surgeon  receives  great  help  from  the  a:-ray.  The 
changes  in  the  sella  turcica  in  hypophyseal  disease  probably  are  of 
greater  importance  than  any  other  sign.  They  consist  of  enlargement 
of  the  sella  or  destruction  of  the  walls.  The  enlargement  finds  its  best 
type  in  the  adipose  genital  form  of  the  disease  when  the  slow  growth 


TUMORS  AND  ALLIED  PROCESSES  IN  THE  BRAIN        357 

in  bone  not  yet  fully  calcified  permits  extensive  distortion  and  new 
growth  of  bone.  This  is  true  in  a  lesser  degree  of  the  changes  occurring 
in  adenomata  growing  later  in  life.  Here  we  may  have  either  enlarge- 
ment or  destruction,  or  both.  The  destruction  involves  particularly 
the  posterior  clinoid  processes  and  the  wall  between  the  sphenoid  cells 
and  the  sella.  In  younger  individuals  there  may  be  an  absence  of  the 
posterior  wall  giving  rise  to  an  erroneous  diagnosis  of  sarcoma,  since 
the  absence  may  be  due  to  early  pressure  with  aplasia  of  the  wall. 
The  malignant  growths  cause  destruction  and  here  the  fragmented 
wall  may  be  seen,  although  it  has  been  my  experience  to  find  this  same 
destruction  in  benign  tumors. 

Destructive  processes,  especially  of  the  mastoid,  may  be  seen  and 
direct  us  to  the  diagnosis  of  an  abscess.  Less  often  may  be  seen  cal- 
cified tumors  and  cysts,  exostoses  pressing  upon  the  brain,  sarcomatous 
or  carcinomatous  destruction  of  bone,  and  aneurysms  (Fig.  104). 


Fig.  104. — Osteoma  of  skull.  These  excessive  bony  deposits  may  at  times  conceal 
an  endothelioma  of  the  meninges;  therefore,  the  surgeon  should  always  examine  the 
underlying  structures. 


Where  tension  is  great  in  young  individuals  a  separation  or  widening 
of  the  fissures  may  be  noted  with  a  deepening  of  the  fossae  or  of  the 
venous  sinus  and  emissary  vein  canals.  The  dilatation  of  the  venous 
canals  may  be  more  apparent  than  real,  since  the  veins  engorged  with 
blood  magnify  the  enlargement.  These  signs  are  for  the  most  part 
general;  exceptionally,  they  may  be  of  localizing  value. 

The  manner  of  taking  the  pictures  is  of  great  importance.  Miss 
Brindley  at  the  Wesley  Memorial  Hospital  Laboratory  has  made  a 


358     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

special  study  of  this  matter  in  my  cases,  and  has  been  enabled  to 
secure  most  excellent  pictures  by  paying  great  attention  to  placing  the 
skull  directly  parallel  to  the  plate.  Care  is  taken  to  see  that  the 
occipital  pfiotuberance,  nasion,  and  the  sagittal  plane  of  the  head  at 
the  vertex,  are  the  same  distance  from  the  plate.  A  diaphragm  picture 
is  then  taken.  Absolute  superposition  of  the  parts  is  necessary  for 
sella  turcica  pictures.  Whenever  the  picture  is  not  clear,  stereoscopic 
plates  are  made.  These  are  always  made  where  there  is  a  question  of 
destruction  or  of  hyperplasia  of  the  skull  proper. 

THE  TREATMENT  OF  BRAIN  TUMORS. 

Craniocerebral  Topography  (Plate  IV)  — The  surgeon  should  so 
familiarize  himself  by  cadaver  study  with  the  general  appearance  of 
the  fissures  and  convolutions  as  to  enable  him  to  recognize  them  at 
sight.  He  should  also  be  able  to  visualize  the  parts  of  the  brain  under 
the  unopened  skull  and  also  the  relation  of  the  ventricles  to  the  various 
convolutions  he  may  have  in  sight.  The  general  relations  of  the  brain 
to  the  cranial  bones  are  as  follows :  The  frontal  bone  covers  the  greater 
part  of  the  frontal  lobe  and  the  whole  of  the  lowest  convolution.  The 
posterior  parts  of  the  other  convolutions  are  covered  by  the  parietal 
bone.  The  frontal  eminence  marks  the  second  convolution.  The 
antero-inferior  angle  of  the  parietal  indicates  the  inferior  frontal  con- 
volution. The  parietal  bones  cover  the  posterior  ends  of  the  upper 
two  frontal  convolutions,  the  central  convolutions,  and  a  part  of  the 
occipital  lobe.  The  parietal  eminence  corresponds  to  the  supramarginal 
gjTus.  The  central  convolutions  lie  more  on  the  top  of  the  brain  than 
the  side;  hence  are  under  the  upper  part  of  the  parietal  bone.  The 
posterior  arm  of  the  Sylvian  fissure  ends  just  below  the  parietal 
eminence,  and  is  therefore  higher  than  one  would  think.  The  temporal 
bone  covers  the  greater  part  of  the  temporal  lobes;  the  highest  point 
of  the  squamous  suture  lying  over  the  Sylvian  fissure.  The  temporal 
muscle  covers  the  temporal  lobes,  lower  frontal  convolutions  and  the 
Sylvian  fissure.  The  zygoma  is  on  a  line  with  the  floor  of  the  middle 
cranial  fossa;  hence  the  lower  level  of  the  temporal  lobe. 

Reid,  Thane,  Horsley,  Ivroenlein,  Froriep,  and  many  others  have 
attempted  to  establish  measurements  that  would  accurately  outline 
the  various  lobes.  Owang  to  the  special  importance  of  localization  in 
the  motor  zone,  these  surgeons  have  placed  especial  emphasis  upon  the 
position  of  the  Sylvian  fissure  and  the  central  sulcus.  The  investiga- 
tions of  Sherrington  which  have  placed  the  motor  centers  in  the  pre- 
central  convolutions  have  simplified  the  mensurations  necessary  since,  as 
Kocher  has  shown,  a  line  drawn  from  the  midpoint  on  the  sagittal  line 
from  the  nasion  to  the  occipital  protuberance  downward  and  forward 
at  an  angle  of  about  60  degrees  to  the  midpoint  of  the  zygoma  roughly 
indicates  the  direction  of  the  top  of  the  precentral  convolution.  I  use 
this  method  in  ordinary  cases.  Where  more  comprehensive  knowledge 
is  needed,  the  Kroenlein  method  is  probably  as  satisfactory  as  any 


PLATE    IV 


FIG.  1 


Craniocerebral  Topography. 


PLATE    V 


Kroenlein's  Method  of  Cerebral  Localization. 


THE  TREATMENT  OF  BRAIN  TUMORS 


359 


(Plate  V)      By  this  a  line  is  drawn  through  the  inferior  edge  of  the 
orbit  and  the  upper  edge  of  the  auditory  meatus.    A  second  line  is 
drawn  parallel  with  this  from  the  upper  edge  of  the  orbit.    Three  per- 
pendiculars are  now  erected:  one  from  the  middle  of  the  zygoma  one 
ill  front  of  the  tragus,  and  one  at  the  posterior  border  of  the  mastoid. 
The  last  is  projected  upward  until  it  meets  the  sagittal  line  drawn 
between  the  nasion  and  the  occipital  protuberance     From  this  point, 
called  the  superior  Rolandic  point,  a  line  is  drawn  forward  and  down- 
ward to  the  point  where  the  upper  horizontal  meets  the  anterior  per- 
pendicular coming  from  the  middle  of  the  zygoma,  this  point  being 
called  the  Sylvian  point.    The  middle  perpendicular  from  m  front  ot 
the  tragus  is  then  projected  up  to  meet  this  oblique  line  drawn  between 
the  superior  Rolandic  point  and  the  Sylvian  point.    The  point  where 
this  meeting  occurs  is  called  the  inferior  Rolandic  point.    The  part  ot 
this  oblique  line  between  the  superior  and  inferior  Rolandic  points 
indicates  the  central  fissure,  and  hence  the  motor  centers  are  m  front 
and  the  sensory  centers  behind.    If  a  second  oblique  line  be  drawn  from 
the  Sylvian  point  upward  and  backward,  bisecting  the  triangle  made 
by  the  Rolandic  line  and  the  upper  base  line,  we  have  the  line  ot  the 
Sylvian  fissure.    The  superior  Rolandic  point  lies  about  2 ^  cm.  back 
of  the  midpoint  of  the  nasio-inionic  line.    These  lines  can  indicate  only 
relatively  the  position  of  the  convolutions,  since  skulls  vary  m  their 
configurations.    However,  they  are  just  as  satisfactory  as  the  various 
craniencephalometers  for  which  there  is  so  little  use  that  description 

is  uimecessary.  „         .  •    ,      x  j    i 

Treatment  of  Tumors.— The  technic  of  cramotomy  is  treated  else- 
where, but  it  remains  for  us  here  to  speak  of  the  techmc  of  reinovai 
of  tumors  in  cases  where  it  is  possible  to  remove  them.  With  the 
entrance  into  the  field  of  the  trained  neurologic  surgeon  and  with  the 
introduction  of  methods  comprising  gentleness  m  handling  the  bram, 
care  in  preventing  hemorrhage,  and  rapidity  of  operating,  our  results 
are  growing  better.  Statistics  show  that  permanent  re  lef  may  be 
hoped  for  in  from  6  to  8  per  cent,  of  cases;  marked  relief  m  fully  30 
per  cent.;  while  in  a  majority  of  the  remainder  some  temporary  amelio- 
ration may  be  hoped  for.  The  mortality  of  the  operation  itself  m  the 
hands  of  the  skilled  American  surgeon  has  been  much  lower  than  m 
European  clinics,  the  fatal  cases  being  attributable  m  a  large  part  to 
the  late  stage  at  which  reUef  is  sought,  although  there  is  still  a  con- 
siderable mortality  incident  to  operation  especially  m  cerebellopontine 
and  MTophvseal  tumors.  While  rapidity  of  operation  has  been  men- 
tioned as  a  desideratum,  it  is  of  small  importance  compared  to  nicety 
of  technic  and  the  prevention  of  hemorrhage. 

Ether  anesthesia  is  used  for  the  most  part  although  prehmmary 
injection  of  the  area  with  novocain  and  adrenalin  seems  to  l^sen  the 
hemorrhage  and  may  lessen  the  amount  of  anesthesia  used,  i  he  held 
of  local  anesthesia  is  being  widened  constantly  and  it  is  possible  to 
do  many  of  these  brain  operations  by  this  method. 

The  patient  should  be  placed  in  as  comfortable  a  position  as  possible 


360     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

not  alone  for  the  benefit  of  the  patient,  but  particularly  for  the  aid  it 
gives  the  surgeon.  The  head  should  be  higher  than  the  body  so  as  to 
lessen  the  hemorrhage  and  then  reduce  the  intracranial  tension.  This 
can  be  produced  by  elevating  the  head  of  the  table  or  by  tipping  the 
whole  table,  the  patient  being  held  in  position  by  straps  or  supports. 
If  the  special  tables  devised  for  supporting  the  head  and  maintaining 
the  body  are  available,  so  much  the  better. 

The  dura  having  been  exposed,  any  large  vessels  that  may  bleed  are 
ligated  with  the  finest  of  catgut  or  silk,  and  the  dura  opened.  Owing 
to  the  increased  intracranial  pressure,  the  brain  will  tend  to  bulge 
through  the  small  primary  slit  in  the  dura,  and  great  care  must  be  used 
to  avoid  injury  to  the  engorged  pial  veins  which  may  give  rise  to  embar- 
rassing hemorrhage.  Small  pledgets  of  moist  cotton  can  be  laid  against 
such  an  area  temporarily,  or  small  pieces  of  the  patient's  muscle-tissue 
may  be  held  firmly  in  place  at  the  site  and  when  once  agglutinated  may 
be  left. 

Ample  opening  of  the  skull  should  be  made  immediately.  The 
beginner  is  tempted  to  make  a  small  opening  and  enlarge  it  where 
necessary,  thus  prolonging  the  operation,  incising  the  dura  disadvan- 
tageously,  and  adding  to  the  shock. 


^-r;^n  ^ 

■A  X.    1\ 

^t,      «■& 

^           \ 

y% 

K           ^^A 

% 

'-^     mi^ 

Fig.  105. — Glioma  with  cyst  formation. 


Shock  when  it  occurs  is  generally  due  to  loss  of  blood  or  excessive 
traumatism,  both  of  which  are  directly  due  to  the  surgeon's  technic; 
therefore  every  possible  precaution  should  be  taken  to  prevent  them. 

Where  the  intracranial  pressure  is  so  great  as  to  interfere  with  opera- 
tive procedures,  a  puncture  of  the  ventricle  should  be  done.  This  will 
facilitate  not  alone  the  operative  procedures  upon  the  brain,  but  also 
will  be  of  material  assistance  in  closing  the  wound.  Corpus  Callosum 
puncture  may  be  made  and  exceptionally,  lumbar  puncture  may  be 
resorted  to,  but  one  should  always  remember  the  especial  danger  that 
accompanies  this  procedure  in  the  presence  of  brain  tumors. 


THE   TREATMENT  OF  BRAIN  TUMORS  361 

AATien  the  field  is  exposed,  search  should  be  made  for  the  tiunor.  If 
it  is  upon  the  surface  and  is  highly  vascular,  if  its  margins  are  ill- 
defined  and  of  soft  consistency,  it  is  probably  a  rapidly  gro^'ing  malig- 
nant tumor  or  a  glioma.  It  is  the  part  of  \\'isdom  to  let  such  tumors 
alone,  for  while  it  is  justifiable  at  times  to  remove  a  small  glioma  in  a 
"  silent"  area,  T^'e  usually  find  that,  added  to  the  danger  of  bleeding  and 
death,  there  is  the  probability  that  the  tumor  will  grow  more  rapidly 
after  attempts  at  removal.  So  marked  is  this  tendency  that  some 
cranial  surgeons  make  it  a  rule  never  to  attempt  to  remove  gliomata. 
Non-vascular  cystic  tumors  may  be  gliomata  lying  somewhat  dormant, 
into  which  hemorrhage  has  occurred  (Fig.  105).  Traumatism  of  these 
tumors  also  gives  rise  to  rapid  growth.-  If  the  gro'^'th  is  firm  and  sharply 
outlined  the  tumor  is  probably  an  endothelioma  and  operation  is  indi- 
cated. If  the  tumor  lies  below  the  cortex  and  can  be  felt  but  not  seen, 
it  speaks  for  a  glioma  which  should  not  be  operated  upon  except  that,  if 
cystic,  it  may  be  gently  aspirated.  If  the  timior  is  well  defined,  how- 
ever, it  may  be  a  cyst  or  abscess  demanding  removal.  A  consideration 
of  the  aspirated  fluid  may  help  us,  but  here  much  good  judgment  is 
called  for. 

Before  we  come  to  consider  the  special  technic  in  the  various  lobes, 
it  may  be  well  to  investigate  the  probable  site  and  nature  of  the  tumors. 
Tooth's  tabulation  of  500  cases  reported  at  the  Seventeenth  Inter- 
national Congress  is  as  follows: 

Table  I. 

Sex. 
Region.  M.  F.         Total.     Per  cent. 

1.  Frontal 60  40  100  21.7 

2.  Central  pre- and  postparietal       ....  43  20  63  13.7 

3.  Temporosphenoidal 24  25  49  10.6 

4.  Occipital 8  6  14  3.0 

5.  Corona  radiata,  corpus  callosiim,  etc.     .      .  4  6  10  2.1 

6.  Lateral  ventricle 2  1  3  0.6 

7.  Pitiaitarv- 10  4  14  3.0 

8.  Optic  thalamus 4  2  6  1.3 

9.  IMesencephalon .18  8  26  5.2 

10.  Pineal 4  ...  4  0.8 

11.  Choroid  plexus;  III  and  IV  ventricles    .       .  4  1  5  1.0 

12.  Cerebellum 44  33  77  16.7 

13.  ExtracerebeUar 19  21  40  8.7 

14.  Pons 19  24  43  9.3 

15.  Med-uUa 1  1  0.2 

16.  Base 1  3  4  0.8 

Total .     264         195         459 

17.  Not  localized 24  17  41 

Grand  total 288         212         500 

Forebraia,  239,  or  52  per  cent. ;  midbrain,  30,  or  6.5  per  cent.;  cerebellum  and  pons, 
160,  or  34.2  per  cent. 

Of  the  group  shown  as  not  localized,  many  are  unquestionably 
located  in  the  frontal  and  temporosphenoidal  regions. 

In  regard  to  the  age  the  author  sums  up  as  follows:  Tumors  of  the 
forebrain  tend  to  appear  more  frequently  in  middle-age,  but  no  age  is 


302     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

exempt.  Those  of  the  midbrain,  on  the  other  hand,  are  most  predomi- 
nant in  the  early  or  adolescent  period,  and  the  same  may  be  said  of 
tumors  of  the  cerebellum  and  pons.  Comparatively  few  occur  here 
after  thu-ty. 

As  to  the  variety  of  the  tumor,  gliomata  comprised  127,  or  49.2 
per  cent.;  fibrogliomata,  15;  fibromata,  13;  endotheliomata,  37;  sarco- 
mata, 21;  carcinomata,  15;  tuberculomata,  14;  simple  cysts,  5;  papillo- 
mata,  3 ;  cholesteatomata,  2 ;  pituitary  tumors,  2 ;  pineal  gland  tumors,  4. 

Cancerous  heredity  was  present  in  37  cases,  or  7.2  per  cent.  In  no 
case  was  there  any  history  of  a  brain  tumor.  Gliomata  were  well 
distributed  throughout  the  brain,  comprising  58  per  cent,  of  all  groA^-ths 
in  the  forebrain,  50  per  cent,  of  those  in  the  midbrain,  and  38.4  per  cent, 
of  those  in  the  cerebellum  and  pons.  Fibrogliomata  and  fibromata  were 
peculiar  to  the  cerebellum,  pons  and  medulla;  endotheliomata  occurred 
only  in  the  anterior  fossa  of  the  skull.  Sarcoma  occurs  in  any  portion 
of  the  brain.  Of  the  21  cases,  6  were  undoubted  round-  or  spindle- 
celled  sarcomata  and  were  secondary;  the  remainder  of  the  cases  were 
primary. 

Of  the  15  carcinomata  only  1  was  unquestionably  primary.  Primary 
tumors  in  7  secondary  cases  were  located;  3  times  in  the  mammary 
gland  and  1  each  in  the  ovary,  suprarenal,  pancreas  and  rectum. 

Cysts  are  said  to  be  more  common  in  the  cerebellum  than  in  other 
parts  of  the  brain.  Of  these  there  are  many  varieties;  parasitic,  der- 
moid, serous  due  to  transformation  of  sanguineous  effusion  or  an  area 
of  softening  or  hemorrhage  into  a  glioma;  and  cysts  due  to  serous 
meningitis. 

Operations  upon  the  frontal  lobes  must  take  into  consideration  the 
extent  of  the  frontal  sinuses,  since  they  may  be  a  source  of  meningitis 
if  the  operation  leads  through  them.  X-ray  pictures  should  be  taken 
accurately  outlining  the  sinuses  before  operation  begins.  Large  tumors 
may  be  removed  without  doing  serious  permanent  damage. 

When  the  tumor  lies  in  the  paracentral  lobules,  great  care  should  be 
taken  not  to  destroy  any  more  of  the  brain  tissue  than  is  absolutely 
necessary.  Here  especially  one  should  be  conservative  in  the  treatment 
of  the  gliomata  for  fear  that  the  final  state  of  the  patient  may  be  worse 
than  the  present.  If  the  cerebral  tension  can  be  lessened  by  a  Cushing 
subtemporal  decompression  it  is  the  operation  of  choice.  Endothelio- 
mata, tuberculomata  and  cysts  should,  however,  be  removed.  One 
cyst  that  was  removed,  by  my  colleague.  Dr.  H.  M.  Richter,  had  grown 
to  such  a  size  as  to  cause  almost  complete  paralysis  on  the  contralateral 
side,  yet  by  gentle  manipulation,  the  fluid  was  aspirated,  and  by  grasp- 
ing the  wall  of  the  cyst  and  twisting  slowly  the  entire  cyst  sac  was 
removed  without  hemorrhage  and  with  an  ultimate  complete  restora- 
tion of  function.  The  adjacent  brain  tissue  should  be  gently  separated 
from  the  tumor  mass  by  a  spatula  covered  with  moist  cotton  or  wiping 
it  off  with  the  cotton-covered  finger  as  the  tumor  is  extracted.  Violent 
tearing  or  cutting  should  be  avoided.  The  tumor  should  ne^'er  be 
"gouged"  out.    Care  should  be  taken  not  to  injure  the  blood  supply 


THE  TREATMENT  OF  BRAIN  TUMORS 


363 


along  the  central  fissure.  It  should  be  remembered  that  the  cortical 
0.5  cm.  is  made  up  largely  of  association  fibers  and  can  therefore  be 
cut  with  much  more  impunity  than  the  lower  lying  pyramidal  cell- 
bearing  tissue. 

The  temperosphenoidal  lobes  are  frequently  the  seat  of  tumors,  and 
especially  upon  the  right  side  may  be  removed  extensively. 

Tumors  of  the  interior  of  the  forebrain  or  midbrain  and  those  involv- 
ing the  ^■entricles  are  inoperable,  and  are  frequently  best  treated  by 
puncture  of  the  corpus  callosum  or  this  associated  with  a  decompression 


Fig.   IC  6. — Central  glioma  producing  marked  hydrocephalus.     (Northwestern  University- 
Medical  School  collection.) 


(Fig.  106).  AYhen  a  tumor  of  the  cortex  is  removed  and  the  resulting 
defect  connects  with  the  ventricle,  no  alarm  need  be  felt,  but  one  may 
here  interpose  a  pad  of  fat  to  fill  the  defect,  being  careful  not  to  use 
too  large  a  piece. 

Tumors  arising  from  the  dura  can  be  removed  without  difficulty 
either  by  peeling  them  oft'  or  removing  the  dura  involved  and  trans- 
planting a  flap  of  fascia  lata  to  take  its  place. 

As  mentioned  above  where  a  cyst  sac  can  be  remoA^ed,  it  should  be 
done.    If  thin  walled  it  may  be  removed  by  grasping  the  edges  of  the 


364     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

opening  and  twisting  slowly  and  gently.  If  this  is  not  feasible,  the 
walls  may  be  cut  away;  or  if  the  wall  is  too  thick  for  this,  it  should  be 
curetted  so  as  to  thin  it  and  favor  collapse.  The  interior  should  be 
painted  with  iodine  to  further  irritate  the  connective  tissue  and  destroy 
any  epithelial  cells,  so  that  union  of  the  collapsed  walls  may  take  place. 
In  exceptional  cases  drainage  either  into  the  subdural  space  or  into  the 
subaponeurotic  space  may  be  indicated.  Elsberg  suggests  a  strip  of 
Cargile  membrane  for  drainage  material.  The  possibility  of  a  cystic 
degeneration  of  a  glioma  should  not  be  forgotten. 


Fig.    107. — Chloroma  of  dura.    The  color  cannot  be  shown  in  the  photograph.     (North- 
western University  Medical  School  collection.) 

Cerebellar  and  Cerebellopontine  Tumors. — Operations  upon  the  cere- 
bellar region  have  two  special  dangers :  hemorrhage  and  the  possibility 
of  involving  medullar  function  producing  sudden  death.  For  these 
reasons  such  operations  are  looked  upon  with  concern  by  the  surgeon. 
The  operations  per  se  upon  the  cerebellum  are  not  dangerous.  Frazier 
says  that  the  whole  of  a  lateral  lobe  may  be  removed  or  destroyed  with- 
out serious  permanent  injiu-y  to  the  patient,  but  after  any  operation 
edema  and  added  pressure  upon  the  medulla  or  the  accumulation  of 
large  clots  or  the  changed  relations  of  the  structures  pressing  upon  the 
medulla  or  the  forcing  of  it  down  into  the  foramen  magnum,  are  sources 
of  real  danger.  To  obviate  these  it  is  wise  to  have  the  patient  in  such  a 
position  that  the  surgeon  is  master  of  the  situation  at  all  times.  The 
lateral,  head-up  position  of  Frazier  is  very  satisfactory,  the  patient 
being  held  in  position  by  arm  supports. 


THE  TREATMENT  OF  BRAIN  TUMORS  365 

Gushing  and  others  have  advocated  bilateral  removal  of  bone  below 
the  transverse  sinuses  and  in  most  cases  the  bone  is  not  replaced.  In 
most  cases  it  may  be  advisable  to  remove  the  posterior  portion  of  the 
bone  about  the  foramen  magnum.  Manipulation  should  be  made  with 
care  so  as  not  to  traumatize  the  pial  vessels  which  will  be  engorged 
and  bleed  profusely  if  extra  tension  is  present.  Frazier  has  considered 
these  operations  in  a  masterful  manner  and  has  emphasized  these 
points  repeatedly,  insisting  that,  if  the  tumors  are  malignant  or  ad- 
herent, no  attempt  at  removal  should  be  made,  a  decompression  being 
the  wiser  procedure.  Special  warning  against  lumbar  puncture  should 
be  given  owing  to  the  danger  of  driving  the  medulla  down  into  the 
foramen  magnum.  He  also  does  not  believe  that  a  bilateral  operation 
is  generally  needed.  Persistent  drainage  of  cerebrospinal  fluid  may 
continue  for  some  days  from  these  wounds  without  serious  conse- 
quences. If  a  cyst  is  found  in  the  cerebellum  it  may  be  removed  with 
especially  good  prognosis.  The  endotheliomata,  fibromata,  and  neuro- 
fibromata  that  appear  are  most  commonly  found  at  the  cerebello- 
pontine angle.  Owing  to  their  frequent  origin  from  the  eighth  nerve, 
they  are  called  acoustic  tumors.  They  may  be  removed  and  at  times 
permanent  cure  results.  The  mortality  incident  to  the  procedure  has, 
however,  been  exceptionally  high.  Von  Eiselsberg  lost  13  out  of  17 
cases  and  as  a  result  speaks  against  removal  when  the  tumors  are  larger 
than  a  walnut,  advising  rather  morcellation  and  partial  removal. 
Other  surgeons  have  had  similar  experiences.  Marx  collected  50  cases 
operated  upon  by  the  Krause  technic  showing  a  mortality  of  7t)  per 
cent.  The  Borchardt  (5  cases)  and  Pause  (4  cases)  operations  have  not 
been  used  often  enough  to  give  a  correct  idea  of  their  value. 

Krause  does  a  unilateral  suboccipital  removal  of  the  bone  going 
down  to  the  foramen  magnum  (Fig.  108) .  The  dura  is  cut  in  flap  form 
and  the  lateral  cerebellar  lobe  gently  retracted  toward  the  middle  and 
upward  exposing  the  petrous  portion  of  the  temporal  bone,  this  is 
followed  inward  until  the  tumor  is  exposed  attached  to  the  eighth 
nerve.  The  facial  nerve  generally  lies  upon  the  tumor  and  should  be 
retracted  to  avoid  injury.  The  tumor  is  gently  enucleated  by  a  thin 
blunt  spatula,  working  the  tumor  upward  and  outward  away  from  the 
medulla.  Elsberg  warns  especially  against  the  use  of  the  finger.  The 
gush  of  cerebrospinal  fluid  that  appears  on  first  exposing  the  tumor 
need  give  no  alarm.  The  tumor  having  been  removed,  the  area  is 
dried,  the  lateral  lobe  allowed  to  fall  back  into  position  and  the  dm-a 
and  muscles  or  muscles  alone  sutured.  Frazier  says  that  he  has  seen 
no  bad  consequences  follow  resection  of  a  cerebellar  lobe  if  this  is 
necessary  to  give  good  exposure.  Rather  than  do  this,  it  may  be  wiser 
to  make  a  two-  or  three-stage  operation.  This  should  be  done  in  any 
instance  where  hemorrhage  threatens  serious  consequences. 

Pause  suggested  reaching  the  tumor  directly  through  the  mastoid 
and  labyrinth  (Fig.  109).  With  the  labyrinth  a  large  part  of  the  petrous 
bone  is  removed  and  the  dilated  internal  meatus  exposed.  Through 
this  opening  the  tumor  is  curetted  away.    Schmiegelow  has  operated 


3G6     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

twice  by  this  method  and  has  had  a  recovery  in  both  cases,  and  Kum- 
mell  and  Quix  in  two  previously  reported  cases  were  also  successful. 


Fig.  108. — Krause  operation  for  cerebellopontine  tumor.     Note  the  distance  from  the 

tumor. 


Fig.   109. — Panse  operation  for  cerebellopontine  tumor. 


THE   TREATMENT  OF  BRAIN  TUMORS 


367 


There  is  great  probability  of  destroying  the  seventh  nerve  by  this  pro- 
cedure, but  in  view  of  the  gravity  of  the  operation  and  the  frequency 
of  paralysis  of  this  nerve  previous  to  the  time  of  the  operation,  the 
saving  of  this  should  not  be  a  desideratum  if  further  experience  demon- 
strates its  safety. 

Borchardt  combines  the  advantages  of  both  of  these  procedures 
(Fig.  110).  He  removes  the  outer  third  of  the  occipital  bone  and  the 
labyrinth  and  mastoid  as  well,  thus  securing  a  larger  opening  for  work. 
This  procediu^e  necessitates  ligating  the  sinus  and  cutting  it  with  the 
dura.  While  the  author  has  never  attempted  the  Borchardt  method,  he 
feels  that  it  has  much  to  recommend  it.  The  unilateral  removal  of  the 
occipital  bone  has,  however,  in  his  hands  been  fairly  satisfactory  smce 


Fig.   110. — Borchardt  operation  for  cerebellopontine  tumor. 

it  permits  of  extensive  dislocation  of  structures  and  provides  ample 
room  for  subsequent  edematous  swelling. 

Hypophyseal  Tumors. — The  reasonable  certainty  of  accurate  localiza- 
tion in  hypophyseal  tumors  gives  fair  encouragement  for  operative 
relief  in  most  and  cure  in  some  cases.  Judged  by  the  criterion  of  return 
to  society  as  a  self-supporting  member,  the  results  of  treatment  may  be 
said  to  be  better  than  in  most  other  brain  tumors.  The  work  of  Gushing, 
Frazier,  Lewis,  Elsberg,  von  Eiselsberg,  Hirsch,  McArthur,  and  earher 
by  Horsley  and  others,  has  been  a  bright  page  in  the  study  of  the  treat- 
ment of  these  tumors.  In  spite  of  this,  however,  we  are  not  able  to 
comit  a  large  number  of  complete  cures.  The  author  has  two  patients 
who  suffered  from  cystic  disease  who  have  been  well  now  a  number  of 
years;  one  for  over  eight  and  one  for  five.    Both  are  self-supporting 


368     TUMORS,   INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

members  of  society,  neither  has  suffered  mental  deterioration,  but 
neither  has  secured  complete  physiological  restoration  as  to  gro'^'th 
and  sexual  function.  Von  Eiselsberg,  Hochenegg,  and  others  report 
similar  experiences. 

The  author  has  elsewhere  discussed  the  various  operative  procedures 
and  the  following  is  modified  from  these  various  contributions.  Many 
routes  have  been  advocated  for  approach  to  the  gland.  The  advan- 
tages and  disadvantages  will  be  discussed  after  considering  the  technical 
points  as  to  the  various  routes. 

The  Intracranial  Routes. — Through  the  Middle  Fossa. — At  the  present 
time  this  route  is  not  used  by  many.  It  was  originally  suggested  by 
Caton  and  Paul  and  was  used  by  Horsley  in  all  of  his  cases.  Dalgren, 
Gushing  and  others  have  attempted  to  follow  the  same  route.  The 
author  has  had  no  experience  with  it,  but  believes  it  is  inferior  to  others 
because  of  its  inherent  difficulties  and  the  fact  that  it  does  not  expose 
the  region  as  satisfactorily  as  does  the  frontal  approach. 

Through  the  Anterior  Fossa. — ^To  ]\IcArthur  and  Bogojowlensky 
should  be  gi^'en  the  credit  of  bringing  again  to  the  attention  of  the  pro- 
fession this  route  which  had  previously  been  suggested  by  Killini  and 
Krause.  The  former  proposed  making  a  dm-al  and  bone  flap  and  ele- 
vating the  frontal  lobe  while  Krause  proposed  an  extradural  route  imder 
the  frontal  lobe  to  the  chiasm.  The  suggestion  of  ]Mc Arthur  to  remove 
the  orbital  ridge  in  addition  to  the  frontal  bone  is  a  landmark  in  this 
procedure.  The  operation  was  still  extradural  down  to  the  optic 
chiasm.  The  ridge  was  removed  separately  from  the  frontal  bone  flap 
but  was  replaced  after  operation.  Frazier  modified  this  by  leaving 
the  orbital  ridge  attached  to  the  frontal  bone,  and  Elsberg,  by  adding 
that  the  flap  should  be  made  with  its  base  inward,  has  made  the 
approach  nearly  ideal  for  those  cases  in  which  the  intracranial  operation 
is  chosen.  Adson's  technic  of  intracranial  approach  described  later  is 
also  highly  recommended.  Elsberg's  technic  is  described  by  himself  as 
follows : 

"  T-rays  having  been  taken  to  determine  the  size  and  extent  of  the 
frontal  sinuses,  the  side  of  the  frontal  bone  is  selected  in  which  the  sinus 
is  the  smallest.  If  the  patient  has  lost  the  sight  of  one  eye,  it  is  best  to 
do  the  operation  on  that  side. 

"An  incision  is  made  from  the  inner  angle  of  the  eyebrow  outward 
to  the  external  angular  process  of  the  frontal  bone,  then  upward  and 
backward  to  within  the  hair  line  and  then  inward  to  near  the  median 
line.  With  an  ordinary  trephine,  openings  are  made  at  the  beginning 
of  the  incision,  just  above  the  external  angular  process  and  at  the 
upper  outer  and  upper  inner  angles  of  the  incision  in  the  soft  parts. 
The  bone  is  cut  in  the  usual  manner  with  Hudson  forceps.  The  soft 
parts  are  slightly  dissected  down  from  the  supraorbital  ridge,  the  roof 
of  the  orbit  about  1  cm.  behind  the  supraorbital  ridge  divided  by  slight 
blows  with  a  small  chisel,  the  supraorbital  ridge  cut  at  each  trephine 
opening  with  a  Gigli  saw  or  sharp  Liston  forceps,  and  the  bone  fractured 
toward  the  median  line.    On  account  of  the  thickness  of  the  bone  in 


THE   TREATMENT  OF  BRAIN   TUMORS 


369 


the  median  line,  it  is  usually  necessary  to  partly  divide  the  base  of  the 
bone  flap  with  the  cranial  forceps  (Fig.  111). 

"  With  various  rongeurs,  the  thin  roof  of  the  orbit  is  removed  down 
to  the  optic  foramen,  care  being  taken  that  the  direction  of  the  rongeur- 
ing  is  correct  so  as  not  to  open  into  the  ethmoid  sinuses,  and  that  the 
periosteum  of  the  orbit  is  not  injured.  As  the  operator  approaches 
the  optic  foramen,  a  long-bladed  rongeur  must  be  used,  the  orbital 
contents  depressed,  and  the  frontal  lobe  in  its  dura  slightly  elevated. 
As  soon  as  the  optic  foramen  is  reached,  and  after  all  oozing  of  blood 
has  been  controlled  by  gauze  pressure,  an  incision  about  3  cm.  long  is 
made  from  the  exposed  anterior  clinoid  process  toward  the  median 


Fig.  111.- 


-Technic  of  Elsberg  approach.     Drawing  furnished  by  the  kindness  of 
Dr.  Elsberg. 


line,  a  small  brain  retractor  introduced  into  the  opening  and  the  frontal 
lobe  elevated.  The  optic  chiasm,  hypophysis,  and  sella  turcica  are 
now  in  good  view. 

"When  the  treatment  of  the  hypophyseal  lesion  has  been  finished, 
the  bone  flap  is  returned  into  place  and  the  soft  parts  sutured  in  the 
usual  manner. 

"The  operation  is  not  at  all  difficult  in  the  hands  of  the  surgeon 
experienced  in  cranial  surgery,  and  an  excellent  exposure  of  the  region 
of  the  hypophysis  is  obtained.  It  is  possible  to  extirpate  or  partially 
remove  a  growth  from  around  the  pituitary  body  in  full  view,  and  the 
operation  is  surgically  very  satisfactory.     The  amount^of  elevation  of 


VOL.  I — 24 


370     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

the  frontal  bone  that  is  necessary  is  not  very  great,  so  that  no  injury 
to  the  brain  should  occur.  The  orbital  roof  should  be  removed  over  an 
area  about  2  cm.  in  width,  and  if  an  ethmoid  sinus  be  opened  it  should 
be  closed  with  a  little  Horsley  wax.  The  supraorbital  ridge  forms 
part  of  the  osteoplastic  flap  which  is  better  than  if  the  bone  is  removed 
in  one  piece  and  later  replaced  as  in  Frazier's  operation.  The  amount 
of  visible  scar  is  very  small,  only  a  small  line  between  the  external 
angular  process  of  the  frontal  bone  and  the  hair  line."     (Fig.  112.) 

In  the  author's  hands  this  operation  has  been  satisfactory  in  certain 
cases  in  which  solid  gro^\i;h  can  be  prognosticated.  If  there  is  much 
evidence  of  brain  pressure,  a  corpus  callosum  puncture  should  be  made 
previous  to  operation  since  excessive  brain  pressure  adds  materially  to 
the  difficulty.    He  has  also  used  a  much  larger  bone  flap  extending  well 


F:gs.  112  and  113. — The  patient  was  operated  upon  by  the  author  after  Elsberg's 
method.  Note  the  manner  in  which  the  scar  can  be  covered  by  the  hair.  (Wesley 
Memorial  Hospital,  No.  50909.) 

back  toward  the  motor  area,  combining  with  this  a  dural  flap  in  some 
cases.  If  there  is  much  brain  pressure  exceptional  care  should  be  taken 
to  remove  the  orbital  ridge  with  the  skull  flap;  otherwise  it  will  be 
diSicult  to  hold  the  orbital  section  in  place. 

Adson  has  developed  a  more  lateral  approach  under  the  frontal  lobe. 
It  is  to  be  highly  commended  not  alone  because  of  the  directness  of  the 
approach  but  also  because  of  the  adequateness  of  the  primary  bone 
flap.  Frazier  has  lately  advocated  an  intradural  approach  through  the 
incision  recommended  by  him,  while  Heuer  and  others  have  also  sug- 
gested a  return  to  this  earlier  method;  but  Adson  has  developed  the 
operative  technic  and  introduced  many  new  features  that  highly 
recommend  his  procedure.  I  quote  the  following  from  his  discription 
of  the  technic : 

"The  patient  is  placed  on  the  operating  table  at  an  angle  of  80 
degrees  with  the  horizontal  plane.  The  head  is  held  back  in  a  position 
to  permit  the  natural  gravitation  of  the  frontal  lobe  from  the  anterior 


THE  TREATMENT  OF  BRAIN  TUMORS  371 

cranial  fossa.  The  anterior  limb  of  the  osteoplastic  flap  corresponds 
to  the  margin  of  the  hairline,  and  this  affords  three-fourths  inch  of 
space  posterior  to  the  external  angular  process  of  the  orbit,  thus  pre- 
venting injmy  to  the  motor  branch  supplying  the  frontal  division  of 
the  occipitofrontalis  and  guarding  against  any  paralysis  of  the  muscle. 
The  incision  is  carried  upward  to  the  median  line  three-fourths  inch 
from  the  longitudinal  sinus;  it  is  then  extended  backward  for  a  distance 
of  three  and  a  half  inches  and  downward  over  the  parietal  eminence 
to  a  position  above  the  middle  of  the  ear. 

"After  the  dura  has  been  exposed  a  flap  is  made  to  permit  the 
exposure  of  the  frontal  lobe,  but  it  is  made  at  right  angles  to  the 
osteoplastic  flap,  which  has  been  broken  in  the  region  of  the  temporal 
bone  and  tmiied  dow^nward.  The  dural  flap  is  permitted  to  remain  in 
position  and  to  cover  the  cortex  of  the  brain,  and  the  frontal  margin 
is  raised  by  tension  sutures  of  silk.  The  brain  substance,  as  well  as  the 
exposed  diu'al  surface,  is  covered  with  warm,  moist  cotton,  which,  in 
turn,  is  covered  by  rubber  tissue. 

"  In  the  elevation  of  the  frontal  lobe,  rubber  tissue  strips  are  placed 
gently  over  the  convolutions  in  a  shingle  effect  in  order  to  give  a 
uniform  pressure  over  the  cortex  as  it  is  elevated  by  the  retractor. 
There  is  very  little  difficulty  with  bleeding  during  this  process;  occasion- 
ally there  is  a  small  venous  communication  between  the  cortex  and 
the  dura.  With  gentle  manipulation  the  optic  commissure  and  the 
hypophyseal  body  are  readily  exposed.  Important  landmarks  during 
the  elevation  of  the  frontal  lobe  are  the  anterior  cranial  fossa,  the 
margin  of  the  lesser  wing  of  the  sphenoid  to  the  anterior  clinoid  process, 
the  right  optic  nerve  and  the  internal  carotid  artery.  The  procedure 
is  then  carried  on  mesially  until  the  commissure  as  well  as  the  left 
optic  nerve  and  the  hypophyseal  body  are  brought  into  view.  A 
gentle  dissection  of  the  tumor  is  then  begun  with  blunt  hooks  to  free 
it  from  the  commissure,  nerves,  and  surrounding  tissue.  Usually  the 
tiunor  is  definitely  encapsulated,  and  if  freed  from  the  constricting 
bands  it  is  readily  elevated.  In  case  there  is  slight  bleeding  it  is 
controlled  by  very  small  pledgets  of  cotton  guarded  by  long  strings  of 
silk  to  prevent  their  loss.  As  the  tumor  is  free  from  the  surrounding 
structm-es  a  septile  snare  is  applied  to  its  pedicle,  which  is  gradually 
constructed  to  control  the  bleeding  and  to  remove  the  tumor  mass. 
The  further  removal  of  the  pituitary  tumor  from  the  sella  turcica  may 
then  be  continued." 

Transsphenoidal  Methods. — Supranasal  Route. — Schloffer  first 
used  this  method.  He  turned  the  nose  to  the  right,  excised  the  turbin- 
ate, the  ethmoid  cells,  and  the  septum,  removed  the  inner  wall  of  the  left 
orbit  down  to  the  optic  foramen  and  the  inner  wall  of  the  antrum  of 
Highmore  with  a  portion  of  the  nasal  projection  of  the  left  superior 
maxilla,  and  then  reached  the  tumor  through  the  sphenoid  sinus. 
Hochenegg,  Moskowicz  and  Tandler,  Chiari,  Michel,  Giordano,  and 
others,  have  modified  the  procedure.  Of  all  these  modifications  that 
of  von  Eiselsberg  is  most  popular.    His  technic^  is  as  follows : 

1  Described  in  Surgery,  Gynecology  and  Obstetrics  (International  Abstracts,  1913, 
xvi,  p.  245). 


372     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

Three  days  before  the  operation  the  patient  receives  2  gm.  urotropin 
daily.  The  coagulabiHty  of  the  blood  is  determined  and  calcium  lactate 
given  if  it  is  delayed.  The  nose  and  throat  are  carefully  examined. 
Anesthesia  with  morphin  and  ether  or  Billroth's  mixture.  The  oper- 
ative field  is  sprayed  with  |  per  cent,  novocain  (H.  Braun),  to  stop 
hemorrhage.  Tamponade  is  accomplished  by  Bellocque's  method.  The 
incision  is  made  along  the  left  nasolabial  groove  up  to  the  glabella, 
over  the  bridge  of  the  nose  to  the  right  palpebral  fissure.  The  nasal 
bone  is  cut  through  with  hammer  and  chisel.  The  philtrum  nasi  is 
cut  at  its  juncture  with  the  upper  lip.  A  large  portion  of  the  septum 
and  vomer  is  detached  with  the  nasal  flap.  The  remains  of  the 
septum,  vomer,  rostrum,  and  the  turbinates  are  next  removed. 

Hemorrhage  is  stopped  with  adrenalin  and  compression.  ■  The 
sphenoid  sinus  is  now  opened,  its  anterior  and  inferior  walls  removed 
and  the  cavity  scraped  out.  The  hypophyseal  tumor  is  usually  exposed 
at  this  stage,  the  dura  is  incised,  and  as  much  of  the  tumor  as  is  thought 
advisable  is  removed  with  a  sharp  spoon  (excochleation).  After  stop- 
ping the  hemorrhage  a  cigarette  drain  is  placed  in  the  defect  and 
fastened  by  a  stitch  around  the  left  nostril.  No  tamponade  is  necessary. 
Finally  the  nasal  cavity  is  cleaned  out,  Bellocque's  tampon  is  removed 
and  the  nasal  flap  sutured  in  its  place. 

Infranasal  Route. — Owing  to  the  danger  of  meningitis  from  exposing 
the  cribriform  plate  and  for  the  purpose  of  simplifying  the  procedure 
it  was  suggested  by  the  author  that  the  sphenoid  should  be  approached 
through  the  inferior  portion  of  the  nose,  thus  avoiding  the  removal  of 
the  ethmoid.  In  his  hands  the  operation  has  been  most  satisfactory. 
He  has  now  modified  the  procedure  as  originally  proposed  in  that  a 
submucous  resection  of  the  septum  is  done,  following  the  suggestion  of 
Hirsch  which  is  certainly  a  distinct  advantage.  Halstead  and  Gushing 
have  since  followed  the  same  route  with  some  modifications  in  technic. 
Instead  of  incising  in  the  nasolateral  fold,  Halstead  raises  the  lip  and 
makes  his  incision  in  the  labiobuccal  fold.  He  has  operated  with  bril- 
liant success  by  this  method.  The  author  has  used  both  the  method 
to  be  described  and  the  Elsberg  method  and  believes  that  certain  cases 
should  be  operated  upon  by  the  infranasal  method  and  others  by  the 
transfrontal. 

The  infranasal  technic  has  been  described  in  the  author's  various 
contributions,  from  which  this  description  is  taken.  Its  steps  are  as 
follows'. 

The  nose  is  packed  with  strips  of  adrenalin  gauze  to  lessen  the 
bleeding.  The  patient  is  placed  in  a  semisitting  position  so  that  the 
blood  will  not  accumulate  in  the  sphenoid  sinus  and  over  the  field  of 
operation.  A  tight  posterior  nasal  gauze  plug  is  inserted.  This  is  not 
necessary  so  much  to  prevent  blood  entering  the  pharynx  since  if  the 
operation  is  done  properly  there  should  be  no  tear  in  the  mucous 
membrane,  but  it  does  prevent  air  escaping  through  the  nares  during 
the  operation.  An  incision  of  the  skin  down  to  the  bone  is  now  made  in 
the  crease  close  under  the  nares  and  the  alse  of  the  nose.    The  nasal 


THE  TREATMENT  OF  BRAIN  TUMORS 


373 


spine  is  cut  and  with  the  greatest  "f  J«^/"°lXA""th': 
raised  from  the  floor  o   the  nose  and  "f  °   *e  7*)^^;       t^i„  and 


Fig.   114.-Position  of  patient  for  hypophysis  operation 


(Author's  method.) 


removal  of  the  posterior  wall,  i.  C  the  anterior  wall »« *efb  turcica- 
TwHrbest  entered  by  a  chisel  and  the  bone  removed  by  a  punch  tor 
I^^TSdural  covering  now  being  cut  the  soft  tumor  mass  appears 

and  may  be  curetted  away.  If  a  «f  -  f<rt5^?i!^tcS^^       gauze 
curetted  and  in  my  experience  should  be  lightly  packea  wa    g 


374     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

saturated  with  a  weak  iodine  solution  to  favor  obliteration  of  the  sac  or 
to  preserve  an  opening  into  the  sphenoid.    If  a  solid  tumor  is  removed, 


Fig.  115. — Line  of  incision  for  author's  operation  of  hypophysectomy.      A  string  is 
attached  to  posterior  nasal  plug. 

no  drainage  is  necessary  if  the  bleeding  is  well  controlled.    The  mucous 
walls  of  the  removed  septum  are  allowed  to  fall  together,  a  subdermal 


nxtcmerab. 
raised 


Fig.  116. — Hypophysectomy — author's  operation.   The  mucous  membrane  is  raised  from 
the  floor  of  the  nose  and  the  septum.    The  bony  spine  is  being  cut. 


stitch  closes  the  skin  wound,  the  nares  are  packed  lightly  for  twenty- 
four  hours  with  bismuth  subnitrate  saturated  gauze  to  stop  the  oozing 


THE  TREATMENT  OF  BRAIN  TUMORS 


375 


of  blood  from  the  nose,  the  posterior  nasal  plug  removed,  and  the 
patient  returned  to  bed. 

The  anesthetic  is  best  given  through  intratracheal  insufHation,  or 
pharyngeal  tube,  although  the  author  has  used  rectal  anesthesia  with 
satisfaction.  The  operator  should  be  familiar  with  the  anatomy  of 
the  anterior  of  the  nose,  especially  the  sphenoid  sinus,  and  the  relations 
of  the  sella  turcica.  He  should  provide  himself  with  proper  instruments 
and  an  excellent  headlight.  No  matter  what  method  of  approach  is 
used,  the  operation  is  diflBcult  and  should  be  undertaken  only  after 
thorough  preparation. 


Fig.  117. — Hypophysectomy — author's  operation.  The  mucous  membrane  has  been 
pushed  to  the  side  by  the  speculum  and  the  septum  removed.  The  speculum  is  long  and 
has  a  set-screw  attached  which  holds  it  in  position. 


Hirsch  has  operated  under  local  anesthesia  with  remarkable  results. 
He  has  described  his  technic  as  follows: 

In  his  earlier  cases  he  removed  the  inferior  and  middle  turbinates 
at  the  first  sitting;  at  the  second,  the  anterior  and  posterior  ethmoids; 
at  the  third,  the  anterior  wall  of  the  sphenoid  with  the  impinging 


376     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

septum;  and  at  the  fourth,  the  anterior  wall  of  the  sella  turcica.  The 
tumor  was  then  removed  by  a  curette.  Later  he  suggested  the  sub- 
mucous route,  and  urged  it  as  a  means  of  lessening  the  dangers  of 
infection.    He  has  described  his  technic  as  follows: 

The  mucous  membrane  of  both  sides  of  the  nasal  septum  is  desensi- 
tized with  a  20  per  cent,  cocain  solution.  An  incision  is  now  made 
along  the  anterior  edge  of  the  quadrangular  cartilage,  through  the 
mucous  membrane  on  one  side,  down  to  the  cartilage,  and  the  mucous 


rnemb-  of  ssptwd) 


Ojpojlbjd^' 


Fig.   118. — Hypophj'sectomy — author's  operation. 


membrane  is  raised  by  means  of  a  raspatorium,  together  with  peri- 
chondrium and  periosteum,  from  the  cartilage  and  bone.  The  cartilage 
is  now  incised  |  cm.  from  the  original  incision  and  a  raspatorium  slipped 
between  the  perichondrium  and  the  cartilage  and  carried  to  the  pos- 
terior border  of  the  septum ;  the  mucous  membrane,  together  with  the 
perichondrium  and  periosteum,  are  now  raised  from  cartilage  and  bone 
on  this  side.  The  membranes  are  now  held  apart  by  a  nasal  speculum 
and  in  this  wav  a  medial  nasal  caA'itv  formed  in  which  one  sees  the  bare 


THE   TREATMENT  OF  BRAIN  TUMORS 


377 


cartilage.  This  is  removed  with  one  sweep  of  the  cartilage  knife,  and 
the  vomer  and  the  perpendicular  plate  of  the  ethmoid  are  resected  with 
the  aid  of  a  bone  forceps.  Up  to  this  point  this  operation  is  identical 
with  Killian's  submucous  septum  resection. 


_  Jcicous  membi'eiiie  of 
opposite  side  of  septum  .  ^^   .^ 

pushed  ba.ck  hy  speculum. ,  ;ty/j«7°.<!i>.-crV'^V 


Fig.  119. — Hypophj^sectomy — author's  operation.  The  mucous  membrane  which  has 
been  removed  by  the  artist  to  show  the  line  of  removal  of  the  septum,  is  preserved  at 
the  operation. 

To  bare  the  wall  of  the  sphenoidal  cavity  it  is  necessary  that  the 
mucous  membrane  of  the  vomer  where  it  joins  the  sphenoid  be  sepa- 
rated from  the  bone.    This  is  very  easily  done,  after  which  the  mucous 


Fig.   120. — Shows  the  wound  closed  with  subcutaneous  stitch,  no  scar  is  visible. 


membrane  is  separated  from  the  anterior  surface  of  the  sphenoid  on 
both  sides  as  far  as  the  ostium  sphenoidale,  so  that  the  raspatorium 
falls  into  the  sphenoidal  cavity.     Now  through  this  sack  of  mucous 


378     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

membrane  one  removes  the  posterior  part  of  the  vomer  and  the  rostrum 
sphenoidale,  with  the  bone  forceps,  and  with  several  strokes  of  a  chisel 
one  breaks  through  the  anterior  wall  of  the  sphenoid  cavity,  and  after 
removing  the  sphenoidal  septum  one  sees  the  h^^pophyseal  prominence 
in  its  entirety. 

After  opening  the  sella  turcica  and  the  dura  of  the  hypophysis  res- 
pecti\-ely,  the  hypophyseal  tumor  lies  free  in  the  sphenoidal  cavity. 

Approach  Through  the  Mouth. — Many  authors  have  suggested 
approach  tlirough  the  antrum  of  Highmore,  or  behind  the  soft  palate, 
but  they  are  not  to  be  recommended. 

Choice  of  Operation. — It  is  natm*al  that  in  any  procedure  in  which 
there  are  so  many  inherent  difficulties  and  in  which  the  outcome  is  not 
always  satisfactory  from  the  technical  standpoint,  there  should  be 


Figs.  121  and  122. — Cyst  of  hj-pophysis.  Note  the  enlargement  of  the  sella  and  the 
eye-grounds  shown  in  Fig.  123.  This  patient  was  operated  upon  three  times  by  the 
author.  The  repeated  operations  were  necessitated  by  the  refilling  of  the  cyst  and 
each  operation  was  done  by  the  infranasal  approach.  Since  the  last  operation,  three 
j-ears  ago,  he  has  remained  well.  The  author  has  a  second  case  with  similar  pathologj-, 
weU  after  five  years.     (Wesley  Memorial  Hospital,  45762.) 


considerable  difference  of  opinion  as  to  the  advisability  of  various 
procedures,  and  also  it  is  easily  understood  why  the  same  surgeon  may 
at  different  times  be  in  favor  of  dift'erent  tj-pes  of  operation.  As  our 
knowledge  grows,  it  is  certain  that  various  modifications  of  procedures 
now  suggested  will  be  made.  For  the  most  part,  however,  adherence 
will  be  giA'en,  it  would  seem,  either  to  an  approach  tlirough  the  frontal 
area  or  infranasally.  It  would  seem  to  the  author  that  the  various  lines 
of  procedure  will  be  indicated  ultimately  by  the  tyipe  of  pathology 
found  in  the  various  cases,  and  as  our  diagnostic  acumen  becomes 
developed  we  will  be  able  to  say  that  for  one  tA-pe  of  disease  one  method 
is  better  suited  and  for  another  t}-pe  of  disease  another  method  of 
approach  is  better.  It  would  seem  that  it  is  not  advisable  for  any 
surgeon  to  become  an  adherent  of  any  one  method  of  procedure,  but 


THE   TREATMENT  OF  BRAIN  TUMORS 


379 


rather  that  he  so  equip  himself  that  he  is  competent  to  approach  hypo- 
physeal tmnors  either  through  the  nose  or  intracranially. 

At  the  present  time  there  is  much  to  be  said  in  favor  of  approaching 
all  hypophyseal  cysts  by  the  mfranasal  route  as  described  by  the 
author.  This  type  of  disease  we  know  to  be  most  common  m  adipose 
types;  Froelich's  syndrome.  The  difficulty  of  removmg  all  of  the 
lining  of  the  cyst  and  the  probability  of  recurrence  if  the  lining  is  not 
destroyed  would  speak  in  favor  of  an  approach  by  which  secondary 


Fig.   123.— Before  operation,  see  Fig.  122  (Case  No.  45,762). 


Fig.  124. — Eye-grounds  in  No.  45,762  (see  Fig.  122)  after  the  first  operation. 

operation  could  be  done  easily  if  desired.  It  is  manifest  that  repeated 
intracranial  operations  would  not  be  looked  upon  with  favor  since  the 
difficulties  would  increase  with  each  operation.  Not  only  is  approach 
through  the  nose  in  secondary  operations  feasible,  but  it  is  really  much 
simpler  in  the  primary  procedure.  The  author  has  in  one  case  operated 
three  times  upon  such  a  cyst  with  complete  primary  recovery,  judged 
by  five  years  of  freedom  from  recurrence.  On  the  other  hand,  the  field 
of  vision  is  not  so  good  through  the  infranasal  approach  as  it  is  through 


380     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

widely  executed  frontal  approach.  Therefore,  there  is  some  justi- 
fication for  the  belief  that  in  many  cases  of  adenoma  the  frontal 
approach  is  to  be  advised.  Against  this,  however,  is  the  fact  that  if  the 
tumor  is  confined  to  the  sella  tiu^cica  it  can  be  completely  removed 
through  the  nose,  probably  with  less  trauma  to  the  cranial  tissues  than 
if  removed  through  the  frontal  route.  This  is  especially  true  in  those 
patients  with  an  increased  intracranial  tension  at  the  time  of  operation. 
The  intracranial  route  is  preferred,  however,  in  a  majority  of  solid 
tumors.  In  favor  of  the  intracranial  route,  is  the  fact  that  neighbor- 
hood tumors  may  be  reached  at  the  same  time  when  one  has  operated 
for  an  intracranial  sellar  tumor  and  it  has  not  been  found.  The  ability 
to  remove  such  tumors  with  permanent  recovery  is  yet  to  be  proved. 


Fig.  125. — A'-ray  picture  of  patient  shown  in  Fig.  122,  taken  forty-eight  hours  after 
operation.  The  dark  shadow  is  the  outline  of  the  cyst  shown  by  the  bismuth  gauze 
which  was  packed  in  the  cyst  after  opening.  The  packing  was  not  done  tightly;  therefore, 
the  cj-st  was  probably  much  hirger. 

The  transsphenoidal  route  gives  a  decompression  opening  in  case  of 
future  growth.  Thus  it  is  possible  to  prolong  life  by  it  in  those  cases 
in  which  complete  removal  of  growing  tumors  is  not  possible. 

In  general  then  it  may  be  said  that  in  those  patients  suffering  from 
cystic  disease,  operation  through  the  nose  has  many  ad\antages  and 
would  seem  to  be  the  method  of  choice.  In  solid  tumors  an  approach 
by  the  intracranial  method,  either  that  practised  by  Frazier  and 
Elsberg  or  that  advocated  by  Adson,  would  seem  to  be  the  method  of 
choice.    Future  experience  may  modify  these  generalizations. 


THE   TREAT MEXT  OF  BRAIX   TUMORS  381 

Indications  for  Operation. — It  may  be  said  that  all  cases  of  li>'po- 
physeal  tumefaction  should  be  operated  upon,  since  even  patients  in 
extreme  condition  have  been  relieved  temporarily.  Operation  is  indi- 
cated absolutely  in  those  patients  in  whom  the  tmnor  jeopardizes 
the  life  of  the  individual  or  is  causing  progressive  blindness.  It  is 
relatively  demanded  for  the  weU- being,  when  ultimately  the  life  of  the 
individual  is  threatened.  Therefore  pressure  s^TQptoms  either  local  or 
general  will  demand  immediate  intervention.  The  pressure  SATQptoms 
may  be  due  to  a  rapidly  growing  tumor  or  to  a  cyst  which  may  be 
enlarging  rapidly  or  which  has  become  suddenly  filled  with  hemorrhagic 
extravasation.  As  our  knowledge  increases  the  field  of  relative  demand 
for  operation  will  be  broadened.  How  far  simple  perversion  of  physio- 
logical action  as  e\'idenced  by  a  lack  of  growth  or  overgro'^'th  (acro- 
megaly) should  uifluence  us  m  operation  must  at  the  present  time  be 
detei mined.  As  the  safety  of  the  procedure  is  mcreased  and  our  knowl- 
edge of  diagnosis  progresses,  it  is  to  be  hoped  that  the  disease  may  be 
attacked  before  the  destruction  or  perversion  of  these  physiological 
actions  may  have  occm-red.  Specifically  we  might  say  that  the  adipose- 
genital  t^-pe  of  disease  where  an  enlarged  sella  can  be  sho^m  is  by  far 
the  most  favorable  subject  for  operation.  Acromegaly  e^'idenced  by 
increased  secretion  apparently  must  at  the  present  time  be  treatai 
conservatively,  particularly  since  many  of  the  cases  at  the  time  they 
are  seen  have  passed  through  into  the  stage  of  h\'popituitarism. 

The  mortality  which  m  the  past  has  been  approximately  35  per  cent, 
will  probably  so  continue  in  the  hands  of  those  doing  little  cranial 
surgery.  Gushing  and  Hirsch  now  report  an  average  of  10  per  cent. 
mortality,  while  the  author  has  operated  upon  15  cases  with  four  deaths, 
all  but  one  of  these  in  the  earlier  cases.  The  patient  has  a  right  to  an 
expression  of  opinion  not  alone  as  to  the  immediate  result  but  also  as 
to  the  ultmiate  result  of  any  operative  procedure.  Our  knowledge  is 
yet  so  incomplete  that  we  cannot  give  an  absolute  prognosis  as  to  either. 
However,  it  would  seem  that  we  may  assure  the  patient  that  good 
results  as  to  local  pressm-e  can  be  assured  in  case  of  cysts.  Horsley 
and  others  have  shown  evidence  as  to  reciurence  after  operation  and  as 
stated  above  m  one  of  the  author's  cases  there  were  two  recurrences 
after  operation.  But  it  would  seem  that  repeated  operations  if  neces- 
sary will  ultimately  end  in  a  destruction  of  the  cyst  and  that  such  cases 
may  remain  well  is  shown  by  the  experience  of  various  surgeons.  The 
brain  pressure  is  relieved,  there  is  no  further  progress  in  the  atrophy 
in  the  eye  gromids,  and  the  eye  signs  become  uniformly  improved 
unless  complete  nerve  atrophy  is  present.  The  excessive  adiposity 
has  been  lessened  or  removed,  although  this  would  seem  to  be  aided 
by  whole  gland  feeding.  There  has  been  little  change  in  the  sexual 
development,  although  von  Eiselsberg  reports  some  improvement  in 
one  of  his  cases.  Xo  marked  change  in  gro-^-th  has  as  yet  been  produced 
by  operation  or  by  gland  feeding.  The  gro^i:h  of  hair  seems  to  be 
improved,  especially  when  gland  feeding  is  instituted.  The  surgeon 
should  bear  in  mind  that  hemorrhages  may  occur  into  the  cyst  giving 


382     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

rise  to  acute  pressure  s\Tnptoms,  these  pressure  symptoms  subsiding 
after  the  absorption  of  the  blood.  Therefore,  an  absolutely  bad  prog- 
nosis cannot  be  given  even  when  operation  is  refused.  It  should  also 
be  borne  in  mind  that  many  of  the  perversions  of  physiology  are  due  not 
alone  to  the  immediate  pressure  but  to  the  previous  destruction  of 
gland  tissue ;  therefore  gland  feeding  should  be  instituted  even  though 
operation  is  not  performed. 

\Miile  some  surgeons  have  reported  an  improvement  following 
operation  upon  acromegaly,  these  results  are  so  indefinite  that  one  is 
inclined  to  be  conservative  regarding  any  physiological  result  which 
can  be  obtained  by  operation.  There  has  been  reduction  in  swelling 
of  the  soft  parts  with  no  effect  upon  bones.  Hochenegg,  von  Eisels- 
berg,  Gushing  and  others  report  the  return  of  sexual  function  one  year 
after  operation  which  was  supplemented  by  gland  feeding.  The  sight 
when  involved  has  been  favorably  affected.  Gushing  has  stated  that 
acromegalics  who  have  gone  over  into  a  state  of  h\T)opituitarism  have 
been  markedly  benefited  by  feeding  the  whole  gland  without  operation. 
It  is  evident,  however,  that  we  are  dealing  with  the  ultimate  stage  of  the 
disease,  and  it  is  to  be  hoped  that  the  time  may  come  when  diagnosis 
may  be  made  early  and  the  operation  be  sufficiently  safe  to  justify 
procedures  in  the  early  stage  of  the  disease  when  it  is  probable  more 
definite  results  may  be  obtained.  Those  intracellar  adenomata  can 
probably  be  removed  with  a  possibility  of  no  recurrence.  ^^Tiere  they 
have  groAMi  beyond  the  sella,  however,  into  surrounding  area,  it  is 
problematical  as  to  how  much  result  will  be  obtained;  although 
improvement  of  symptoms  produced  by  local  pressure  and  the 
amelioration  of  some  general  s\Tnptoms  may  be  expected  at  least 
temporarily. 

Pineal  Gland  Tumors. — Tumors  of  the  pineal  gland  have  been  con- 
sidered inoperable  although  attempts  at  removal  have  been  made. 
^^^lile  the  operation  should  be  considered  a  desperate  undertaking, 
experience  has  sho\Mi  that  it  may  be  feasible.  Pussep  made  a  horse- 
shoe-shaped incision,  the  center  of  which  was  four  fingers  above  the 
occipital  protuberance,  the  ends  curving  down  to  the  level  of  the 
mastoid  processes  and  one  and  one-half  fingers  inside.  The  underlying 
bone  was  removed,  and  the  wound  closed.  The  second  stage  of  the 
operation,  six  days  later,  consisted  in  ligating  the  occipital  sinus  and 
cutting  the  dura  under  the  transverse  sinuses.  The  right  transverse 
sinus  was  ligated  and  cut.  The  dura  along  the  longitudinal  sinus 
upward  and  the  tentorium  inward,  were  cut.  The  occipital  lobe  being 
retracted,  showed  a  cyst  of  the  pineal  gland.  This  was  aspirated, 
some  of  the  wall  cut  away,  and  the  remainder  packed  and  the  wound 
closed.  So  much  cerebrospinal  fluid  escaped  on  the  first  day  that  the 
packing  was  removed  and  the  wound  closed.  The  patient  died  on 
the  third  day,  but  lived  long  enough  to  demonstrate  the  feasibility 
of  the  procedure. 

Rorschach  has  gone  down  beside  the  falx  and  cut  the  posterior 
portion  of  the  corpus  callosum.    No  tumor  was  found,  but  the  only 


THE  TREATMENT  OF  BRAIN  TUMORS 


383 


untoward  result  was  a  transitory  paralysis  of  a  leg  and  slight  inter- 
ference with  sensation. 

Nasetti  has  operated  similarly  except  that  he  ligated  the  longi- 
tudinal sinus  and  cut  the  falx,  then  incising  the  corpus  callosum. 

Removal  of  Tumors  of  the  Gasserian  Ganglion  is  not  exceptionally 
difficult.  The  method  of  attack  is  the  same  as  for  removal  of  the 
ganglion  for  trifacial  neuralgia.  The  tumors  are  not  common  and  are 
endotheliomata,  arising  from  the  dural  sheath. 

Puncture  of  the  Brain  and  Ventricles. — Punctures  of  the  Corpus 
Callosum. — This  procedure  carried  out  for  diagnostic  and  therapeutic 
purposes  is  a  measure  of  considerable  value  in  some  cases.  It  has  been 
used  most  often  in  hydrocephalus,  hypophyseal,  cerebellar,  and  other 


^^^^^^^W^l^ 


Fig.  126. — Schematic  drawing  representing  a  few  of  the  areas  in  which  tumors  may 
especially  produce  hydrocephalus. 


tumors  which  have  caused  large  accumulations  of  fluid  in  the  ventricles 
(Fig.  126).  The  principles  upon  w^hich  it  is  supposed  to  act  is  that  if 
in  cases  where  the  pressure  is  high,  an  opening  be  made  through  the 
corpus  callosum  connecting  the  subarachnoid  and  ventricular  spaces 
between  the  hemispheres,  the  intraventricular  pressure  will  tend  to  keep 
the  opening  patent  and  thus  provide  a  permanent  drainage  into  a  space 
where  absorption  of  the  secreted  fluid  is  freer  than  in  the  ventricle. 
While  the  beneficial  results  in  my  hands  have  not  been  so  brilliant  as 
those  reported  by  Anton  and  others,  a  moderate  use  of  the  procedure 
has  convinced  me  that  in  certain  cases  we  may  expect  great  relief  from 
pressure  symptoms  through  puncture,  and  in  a  few  cases  a  sjTuptomatic 
cure.    There  is  very  little  danger  attached  to  the  procedure.    Veins 


384     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

may  be  injured  leading  to  troublesome  hemorrhages,  or  too  deep 
puncture  may  injure  the  optic  thalamus  with  temporary  impairment. 
This  is  especially  to  be  feared  in  basal  tumors  distorting  the  ventricle. 
No  bad  result  has  occurred  in  my  experience  except  that  in  one  patient 
there  was  a  temporary  paralysis  of  the  arm ;  whether  due  to  making  the 
puncture  too  far  back  or  to  a  change  in  pressure  of  the  unlocaliz^ed 
tumor,  was  not  knowii  (Fis:.  127). 


Fig.   127. — Technic  of  corpus  callosum  puncture. 


Technic. — If  the  patient  is  not  nervous  the  operation  may  be  per- 
formed under  local  anesthesia.  In  such  cases  it  is  my  custom  to  give, 
unless  contra-indicated,  a  preliminary  dose  of  scopolamine  ^ho  S^- 
and  morphin  |  gr.  two  hours  and  one  hour  before  operation.  The  area 
being  infiltrated,  a  longitudinal  incision  is  made  running  backward 
from  the  coronal  suture  and  parallel  to  the  longitudinal  suture.  The 
skin  and  the  aponeurosis  of  the  occipitofrontalis  are  retracted  by  the 
ordinary  mastoid  retractor.  A  trephine  now  removes  a  button  of  bone 
the  center  of  which  is  about  2  cm.  from  the  coronal  suture  and  the  same 
distance  from  the  longitudinal.  A  slit  is  made  in  a  non-vascular  part 
of  the  dura  which  is  retracted  with  fine  retractors,  A  puncture  needle 
is  chosen  that  has  a  blunt  end.    Elsberg  uses  a  needle  devised  by  him- 


THE   TREATMENT  OF  BRAIN  TUMORS  385 

self  in  which  the  end  is  slightly  bulbous  with  holes  at  the  end  and  side. 
Before  learning  of  this  the  author  had  devised  a  needle  somewhat 
similar  having,  however,  a  more  olive-pointed  tip  and  the  upper  end 
flattened  so  the  more  perfect  orientation  at  the  concealed  point  is 
possible.  The  olive  point  enters  the  corpus  easily  but  offers  some 
resistance  to  withdrawal,  thus  indicating  its  position  (see  Fig.  128). 
The  needle  should  be  flexible,  with  a  stylette,  and  should  be  at  least 
10  cm.  long;  The  needle  is  bent  at  an  angle  of  about  90°,  approxi- 
mately 6  cm.  from  the  end,  since  this  is  the  average  distance  from  the 
surface  of  the  brain  to  the  ventricle.  A  few  small  veins  pass  from  the 
cortex  veins  to  the  longitudinal  sinus  and  in  most  cases  there  is  a  slight 
adhesion  of  the  cortex  to  the  longitudinal  sinus.  The  needle  is  gently 
passed  through  this  area  and  rotated  downward  along  the  falx  cerebri. 
A  slight  resistance  is  felt  when  the  corpus  callosmn  is  reached.  The  end 
of  the  needle  is  gently  moved  back  and  forth  to  avoid  penetrating  the 
pial  vessels  and  then  is  thrust  through  the  corpus  and  the  stylette 
removed.  If  tension  is  present,  the  fluid  flows  out  freely.  The  needle 
end  is  rotated  back  and  forward  for  about  a  centimeter  to  tear  the 
corpus  callosum  and  then  is  withdrawn.    Care  should  be  taken  not  to 


Q; 


V.MUELLERS  CO. 


Fig.   128. — Modified  needle  used  in  corpus  callosum  puncture. 

go  too  far  forward  and  miss  the  ventricle  and  too  far  backward  and  do 
injury  to  important  structures.  The  dura  is  closed,  the  bone  plug 
replaced  or  not  as  desired,  and  the  wound  closed. 

Puncture  of  the"  Ventricles. — If  the  thhd  ventricle  be  dilated  it  may  be 
reached  tlirough  the  corpus  callosum  punctiue  just  described;  if  not, 
the  punctm-e  will  reach  a  lateral  ventricle.  Other  sites  for  punctme 
of  the  lateral  ventricles  may  be  chosen  and  in  ordinary  cases  where 
we  wish  to  aspirate  them  for  diagnosis  or  for  therapeutic  purposes, 
these  locations  are  preferable.  The  relation  of  the  ventricles  may 
be  seen  from  examining  Plate  IV.  It  should  be  remembered  that  the 
ventricle  lies  nearer  the  median  line  than  the  beginner  would  belie^'e. 
The  known  centers  should  be  avoided  and  care  used  not  to  mjure  pial 
vessels  or  to  direct  the  needle  toward  the  choroid  plexus  or  the  island 
of  Reil  where  hemorrhage  is  very  likely  to  occm*.  Again,  the  needle 
should  be  thrust  directly  into  the  ventricle  and  not  moved  about  after 
the  puncture  is  started.  In  the  hands  of  the  expert  operator,  pmicture 
may  be  made  from  almost  any  site.  Kocher,  Keen,  Neisser  and  Pol- 
lock, and  others  have  drawn  attention  to  points  of  election.  Kocher' s 
point  is  2^  cm.  from  the  median  line  and  3  cm.  anterior  to  the  central 
fissure.  The  ventricle  lies  at  a  depth  of  4  to  5  cm.  and  the  widest  part, 
2  cm.  in  width,  is  somewhat  backward.    Keen's  point  is  about  3  cm. 

VOL.  I — 25 


386     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

behind  and  3  cm.  above  the  external  auditory  meatus.  The  needle  is 
carried  in  about  5  cm.  in  the  direction  of  the  opposite  pinna.  This 
strikes  the  ventricle  where  the  lateral  and  posterior  cornua  are  given 
off  from  the  body  of  the  ventricle  at  the  posterior  end  of  the  thalamus. 

The  pimctm-e  can  be  made  under  morphin  |  and  scopolamine 
■j^-^  in  divided  doses,  with  local  anesthesia  for  the  scalp  and  even 
without  the  latter  if  a  rapidly  moving  hand  power  small  drill  2  to  4  mm. 
in  diameter  is  used  to  go  through  the  scalp  and  skull.  If  a  craniotomy 
has  been  done  one  remembers  that  Keen's  point  corresponds  to  the 
posterior  part  of  the  first  temporal  convolution.  If  the  frontal  lobes 
are  exposed,  the  anterior  cornu  is  reached  best  tlirough  the  second 
frontal  gjTus  about  1^  cm.  from  the  median  line.  In  children  the 
ventricle  may  be  reached  by  puncture  through  the  lateral  angle  of  the 
anterior  fontanelle,  the  needle  being  directed  slightly  backward  and 
downward. 

Puncture  of  the  Brain  Substances. — The  first  systematic  description 
of  brain  puncture  was  given  by  Schmidt,  but  Neisser  and  Pollock  have 
given  us  the  most  comprehensive  clinical  article  upon  the  subject. 
They  have  located  the  points  of  predilection  for  diagnostic  puncture 
and  demonstrated  that  it  can  be  done  without  great  danger  to  the 
patient.  On  the  other  hand,  there  is  a  real  possibility  of  injury  to  the 
pial  vessels  and  sinuses;  therefore,  blind  puncture  should  be  resorted 
to  only  in  exceptional  cases.  It  is  far  better  to  remove  a  button  of 
bone  and  thus  avoid  any  possibility  of  injuring  the  vessels  or  sinuses. 
The  procedure  is  carried  out  by  means  of  a  medimii- sized  needle  with 
a  stylette.  Neisser  uses  a  graduated  platinum-iridium  needle,  7  cm. 
long  and  1.06  mm.  thick,  with  an  oblique  point.  The  needle  is  inserted 
3  to  4  cm.  The  stylette  is  withdrawn  and,  if  fluid  or  pus  is  present,  it 
can  be  determined  readily.  If  search  is  being  made  for  a  solid  tumor, 
aspiration  is  now  done  and  the  small  particles  drawn  into  the  needle 
examined  microscopically.  It  is  evident  that  in  the  latter  instance  the 
results  obtained  are  far  from  satisfactory.  The  educated  finger  may, 
however,  obtain  data  of  value  as  to  density  of  the  tissue  penetrated  and 
in  case  of  cyst,  abscess,  or  hydrocephalus,  real  knowledge  may  be 
secured.    Neisser  and  Pollock's  article^  illustrates  the  points  of  election. 

CEPHALOCELE. 

Diagnosis. — ^The  diagnosis  of  cephalocele  rests  upon  the  congenital 
nature  of  the  condition,  the  location  of  the  tumor  in  the  lines  of  fetal 
closme  of  the  skull,  and  the  physical  characteristics.  While  cephalocele 
may  grow  large  after  bu-th  they  are  always  congenital,  and  are  to  be 
found  especially  in  the  median  line  in  the  occipital  or  lower  frontal 
region,  the  latter  being  most  common.  They  may  appear  at  the  base 
between  the  ethmoid  and  sphenoid  projecting  into  the  nasal  cavity, 
where  they  may  be  mistaken  for  polyps.    Such  a  case  is  reported  by 

1  Die  Hirnpunktion,  Mitt.  a.  d.  Grenzgeb.  a.  d.  Med.  u.  Chir.,  xiii,  807. 


CEPHALOCELE  387 

Christian  Fenger,  in  Avhich  an  error  in  diagnosis  led  to  operation  and 
death.  Cephalocele  occuiTing  in  the  occipital  region  may  emerge 
above  or  below  the  occipital  protuberance,  communicating  in  the 
former  instance  with  the  posterior  fontanelle  and  in  the  latter  with 
the  foramen  magnum.  Those  which  appear  in  front  emerge  through  the 
horizontal  plate  of  the  ethmoid  and  appear  above  or  below  the  nasal 
bones,  the  former  being  most  common. 

On  examination  cephalocele  may  be  translucent  or  opaque,  varying 
with  the  contents  of  the  sac  which  may  be  made  up  almost  entirely  of 
cerebrospinal  fluid  or,  in  rare  instances,  brain  tissue  alone.  The  char- 
acter of  the  sac  and  the  contents  gives  the  name  to  the  various  types: 
meningocele,  or  better  hydrencephalocele;  myelocystocele;  kenen- 
cephalocele  (Heinecke);  myelocystomeningocele;  encephalocysto- 
meningocele.  Histological  examination  of  the  sac  wall  shows  skin,  sub- 
cutaneous tissue,  arachnoid  membrane,  either  cystic  or  non-cystic,  and 
a  layer  of  tissue  which  may  be  either  the  ependymal  lining  alone  of  the 
ventricle  or  a  thin  or  thick  layer  of  brain  tissue  lined  with  this  ependyma. 
In  other  words,  the  interior  of  the  tumor  is  continuous  with  a  ventricle; 
the  pericranium,  skull,  and  dm*a  being  absent.  The  pericraniiun 
and  dura  generally  merge  into  each  other  at  the  base  of  the  tumor.  If 
the  tumor  contains  only  the  ependjTual  lining  it  is  called  a  hydren- 
cephalocele; if  some  brain  tissue  be  present  with  considerable  fluid, 
it  is  a  myelocystocele;  if  the  arachnoid  be  the  seat  of  cystic  degener- 
ation, it  may  be  either  a  myelocystomeningocele  or  an  encephab- 
cystomeningocele.  It  will  be  seen,  therefore,  that  pure  meningocele  is 
extremely  uncommon  as  first  shown  by  INIuscatello.  The  opening  into 
the  ventricle  proper  may  be  very  small. 

The  tiunors  may  be  of  any  shape  from  flat  to  pedmiculated ;  the 
skin  may  be  loose  or  tense;  they  may  or  may  not  be  translucent,  solid, 
or  fluctuating;  they  may  or  may  not  pulsate.  Attempts  to  expel  the 
contents  of  the  sac  into  the  brain  cavity  should  not  be  made  since  the 
increase  of  brain  pressure  may  give  rise  to  alarming  symptoms;  but 
lumbar  or  tumor  punctm-e  to  study  the  content  or,  in  the  former 
instance,  the  decrease  of  tension,  is  justifiable.  Dermoids  may  occur 
at  these  sites  and  are  differentiated  by  the  physical  characteristics  and 
the  result  of  puncture. 

Treatment. — Cases  of  encephalocele  with  exencephalus  live  only  a 
short  time  and  hence  are  inoperable.  The  same  may  be  said  foe  those 
cases  complicated  with  hydrocephalus  or  severe  congenital  lesions 
destroying  the  brain,  or  those  arising  from  deep  portions  of  the  brain 
invoh'ing  vital  structm-es  such  as  the  medulla  or  the  basal  ganglia. 
Where  there  is  a  fairly  well  developed  head,  however,  with  the  cephalo- 
cele engrafted  upon  it,  operation  is  fiequently  followed  by  good  results, 
the  results  being  in  inverse  ratio  to  the  amount  of  brain  tissue  in  the 
sac.  The  presence  of  some  brain  tissue  does  not  necessarily  preclude 
operation  since  the  function  of  the  portion  of  the  frontal  lobes  destroyed 
may  be  taken  over  by  that  lemaining.  The  cases  with  small  pedicles 
and  little  brain  tissue  give  especially  good  results. 


388     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

The  tumor  should  be  removed  at  the  base,  making  no  attempt  to 
replace  any  brain  tissue.  A  considerable  amount  of  cerebrospinal  fluid 
may  be  lost  without  endangering  the  life  of  the  patient,  but  provision 
should  be  made  to  prevent  such  loss  by  placing  the  patient  in  such  a 
position  during  the  operation  as  to  prevent  the  escape  of  the  fluid. 
The  lining  membrane  should  be  sutured  together,  the  neck  of  the  sac 
isolated  from  the  siu'rounding  bone,  and  the  edges  brought  together  if 
possible.  If  this  is  not  possible  or  if  the  union  is  seen  to  be  weak,  a 
layer  of  fascia  lata  should  be  transplanted  to  cover  the  defect  and 
carefully  sutured  to  the  outer  siu'face  of  the  surrounding  dura  allowing 
the  edges  to  lie  under  the  bone.  If  possible  a  flap  of  bone  from  the 
adjacent  region  should  be  transplanted  to  cover  the  defect.  This 
latter  is  often  not  feasible  and  frequently  not  necessary.  Because  of 
the  age  and  general  condition  of  these  patients,  osteoplastic  and  compli- 
cated operations  are  not  generally  indicated. 

HYDROCEPHALUS. 

Diagnosis. — The  diagnosis  of  the  presence  of  hydrocephalus  is  made 
easy  by  the  well-known  characteristics  presented  by  the  condition. 
The  skull  is  large'with  a  flaring  vertex,  overhanging  the  facial  bones; 
if  young,  the  fontanelles  are  not  closed  and  the  sutures  may  not  be 
united,  and  through  the  thinned  skin  the  veins  engorged  by  the 


Fig.   129. — Hydrocephalus. 


increased  intracranial  tension  show  plainly  (Fig.  129).  .  As  the  disease 
progresses,  destruction  of  brain  tissue  and  pressure  upon  the  tracts 
leads  to  mental  deterioration,  rigidities  of  the  muscles,  with  spasms, 
etc.*tlf  the  condition  comes  on  later  in  life  the  hardening  of  the  bones 
may  preclude  the  marked  changes  to  be  seen  externally,  but  within  the 
process  may  be  more  intense.    External  hydrocephalus  is  uncommon. 


HYDROCEPHALUS 


389 


although  we  may  have  a  spurious  external  hydrocephalus  due  to  serous 
meningitis,  cystic  change  in  the  arachnoid,  and  the  local  degeneration 
of  brain  tissue  with  fluid  formation  and  perforation  into  the  subdural 
space,  such  as  may  occur  in  cerebral  hemorrhage  in  the  newborn. 

Internal  hydrocephalus  is  the  more  common.  For  the  purposes  of 
treatment  a  diagnosis  should  be  made  as  to  the  location  of  the  obstruc- 
tion if  one  is  present,  since  it  is  xery  important  to  know  whether  the 
serum  passes  freely  into  the  fourth  ventricle  and  the  spinal  subarach- 
noid space.  Obstruction  is  most  often  seen  at  the  foramina  of  INIonro 
or  Majendie  or  along  the  iter.  In  the  true  form  this  closure  is  probably 
due  to  inflammation  but  it  may  be  seen  as  a  result  of  tumor  formation 
pressing  upon  the  walls  and  thus  obstructing  the  exit  of  the  serum 
(Fig.  130) .    In  many  cases  on  examination  no  obstruction  can  be  found. 


Fig.  130. — Internal  hydrocephalus,  probably  inflammatorj^  but  possibly  due  to  hypo- 
physeal cyst.  FoUo'ning  subtemporal  decompression  during  the  acute  stage  papillitis 
disappeared  and  the  patient  has  had  no  symptoms  for  six  years.  Note  the  decompression 
tumefaction  upon  the  right  side. 


Treatment. — ^For  the  purpose  of  treatment,  the  surgeon  should 
determine  if  possible  if  obstruction  is  present.  In  those  cases  in  which 
lumbar  puncture  fails  to  relieve  the  excessive  cranial  pressure,  we 
assume  such  obstruction  to  be  present  and  direct  our  surgical  pro- 
cedures to  the  cranium.  If  no  obstruction  is  found,  either  lumbar 
or  cranial  drainage  may  be  instituted. 

Unfortunately  no  procedure  has  been  found  to  be  of  great  avail  in 
this  condition.  Failure  has  been  due  chiefly  to  two  causes:  (1)  the 
altered  condition  of  the  brain  at  the  time  the  patient  is  presented  for 
treatment  (Fig.  131),  and  (2)  the  inability  of  the  surgeon  to  produce 
continuous  drainage  owing  to  connective-tissue  growth  about  the  size 
of  the  drainage  tube.  To  correct  the  first,  all  physicians  should  be 
urged  to  present  the  cases  for  as  early  operation  as  possible.    Various 


390     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

procedures  have  been  suggested  to  overcome  the  second  difficulty. 
Unfortunately,  none  are  particularly  satisfactory.  Direct  puncture  of 
the  ventricles  through  either  Keen's  or  Kocher's  point  {vide  supra), 
followed  by  the  insertion  of  tubes  of  various  material  such  as  glass, 
silver,  etc.,  has  often  been  tried  with  isolated  successes.  These  tubes 
may  reach  to  the  subdural  space  or  into  the  subcutaneous  tissue.  In 
either  case,  scar-tissue  is  likely  to  interfere  soon.  To  obviate  this, 
PajT  suggested  transplanting  living  veins,  either  in  continuity  with  the 
vascular  system  or  into  the  subdural  space.  The  author  has  had  some 
experience  with  this  procedure.  Temporarily  the  cases  were  reliev^ed, 
but  ultimately  they  ceased  to  drain.    Others  have  made  living  tubes 


Fig.   131. — Moderate  degree  of  hydrocephalus  showing  brain  change. 

of  dura,  witli  probably  no  better  success.  ]Murphy  suggested  dram- 
age  of  the  fourth  ventricle  by  opening  through  the  roof,  and  lately 
HajTies  has  tried  to  insert  a  silver  tube  from  the  fourth  ventricle  to  the 
lateral  sinus.  Ha^Ties  makes  an  incision  from  the  occipital  protuber- 
ance to  the  foramen  magnum,  somewhat  to  one  side.  The  bone  is 
removed  up  to  and  over  the  sinus.  A  purse-string  suture  holds  one 
end  of  a  specially  prepared  angular  tube  in  the  roof  of  the  ventricle 
and  the  opposite  end  in  the  sinus.  Owing  to  especially  favorable  con- 
ditions any  of  these  procedures  may  at  times  be  successful,  but  for  the 
most  part  they  are  doomed  to  failure.  Anton  has  reported  several 
cases  treated  by  corpus  callosum  puncture  {iride  supra)  with  marked 
relief,  and  to  this  the  author  can  add  his  experience.    While  it  is  often 


TURMSCHADEL  AND  OXYCEPHALIA  391 

not  satisfactory,  in  several  cases,  both  of  acquired  hydrocephalus  due 
to  tumor  and  other  conditions,  and  in  the  infantile  type,  the  results 
have  been  all  that  could  be  expected. 

In  those  cases  in  which  communication  is  free  into  the  subarachnoid, 
spinal  space,  drainage  may  be  instituted  in  the  lumbar  region,  either 
anteriorly  or  posteriorly.  The  technic  here  also  has  the  same  dis- 
advantage as  that  instituted  on  the  cranium.  Metal  tubes,  silk, 
veins,  arteries,  etc.,  have  all  been  used.  Gushing  suggests  doing  a 
laparotomy,  splitting  the  peritoneum  to  the  left  of  the  rectum,  trephin- 
ing the  fifth  lumbar  vertebra,  and  inserting  the  female  half  of  a  silver 
cannula  do'uai  to  the  spinal  dura.  The  child  is  now  turned  over  and  a 
laminectomy  done,  the  subarachnoid  space  opened,  strands  of  cauda 
separated,  and  the  male  portion  of  the  cannula  locked  in  the  female. 
The  wounds  are  closed  and  the  fluid  escapes  into  the  retroperitoneal 
tissue,  unless  connective  tissue  obliterates  the  opening.  The  same 
procedure  may  be  carried  out  by  using  the  patient's  saphenous  vein. 
The  vein  is  sutured  in  place,  fat  being  left  on  the  vein  to  prevent 
collapse.  In  a  majority  of  cases  any  of  these  procedures  end  in  failure. 
At  times  in  acute  hydrocephalus,  repeated  lumbar  puncture  may  appar- 
ently produce  a  cure. 

HERNIA  CEREBRI. 

Treatment.- — This  lamentable  condition  generally  presupposes  one 
or  both  of  two  conditions;  increased  intracranial  pressure,  and  infec- 
tion. The  treatment  is  based  upon  the  removal  or  lessening  of  the 
protrusion  and  procedures  designed  to  retain  the  structure.  As  a 
preliminary  the  intracranial  tension  should  be  lowered  and  this  is  best 
done  by  lumbar  puncture,  frequently  repeated.  If  the  tension  is 
intracranial,  ventricular  puncture  may  be  indicated.  If  this  is  not 
sufficient,  the  protruding  mass  may  be  removed,  especially  if  it  com- 
prises a  "silent"  area.  The  pericranial  tissue  may  now  be  sutured 
over  the  area  with  tension  sutures,  and  in  favorable  cases  a  flap  of 
fascia  lata  may  be  inserted  although  infection  which  is  commonly 
present  may  preclude  this  procedure  or  vitiate  the  result.  Osteoplastic 
flaps  after  the  Koenig  method  may  be  used.  Where  the  tension  is  not 
too  great,  or  where  the  opening  is  small  or  the  protrudmg  brain  tissue 
sloughs  off,  granulation-tissue  will  spring  up  and  the  wound  heal  by 
cicatrization  or  be  covered  by  Thiersch  grafts. 

TURMSCHADEL  AND  OXYCEPHALIA. 

This  condition  has  been  supposed  to  be  due  to  a  congenital  or 
premature  closure  of  the  fissures  in  the  skull  (Fig.  132).  If  the  fissures 
at  the  base  and  the  sides  are  closed  thus  early,  there  is  a  tendency  for 
the  skull  to  grow  upward  presenting  the  appearance  shown  in  the 
photograph.  This  naturally  leads  to  an  increase  of  intracranial 
pressure  as  evidenced  by  intense  headache,  the  early  development  of 
optic  atrophy  and  proptosis  of  the  eyeball.    The  condition  is  one  not 


392     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

readily  amenable  to  surgical  intervention.  Discovered  early,  however, 
an  extensive  decompression  operation  may  be  done.  To  prevent  the 
secondary  changes  in  the  eye  due  to  turmschadel,  .^chloffer  has  advo- 
cated in  certain  cases  removing  the  roof  of  the  orbit  and  that  section 
of  the  bone  through  which  the  optic  nerve  escapes  from  the  skull. 


Fig.   132. — Turmschadel. 


INFLAMMATIONS  OF  THE  BRAIN  AND  THE  MENINGES. 

Pachymeningitis  Externa.^ — This  condition  associated  with  coinci- 
dent osteomyelitis,  syphilis  of  the  bone,  erysipelas,  tumors,  etc.,  should 
not  be  considered  as  a  special  disease.  Since  the  process  is  localized, 
the  signs  are  those  of  the  causative  disease  with  some  evidences  of 
subjacent  brain  irritation  or  pressure.  These  latter  are  slight  as  a 
rule.  Prompt  removal  of  the  cause  with  adequate  drainage  will  gener- 
ally relieve  the  condition.  In  the  acute  inflammatory  disease,  e.  g., 
otitis  media,  unless  prompt  treatment  is  instituted  it  may  lead  to  an 
acute  leptomeningitis. 

Pachymeningitis  Interna  Hemorrhagica. — Whether  this  condition  is 
due  to  an  inflammation  as  maintained  by  Virchow,  Hesche,  and  Barrat, 
or  to  a  hemorrhage  followed  by  organization  (Spiller,  McCarthy)  is 
open  to  question.  Pathologically  early  we  see  a  delicate  pink  or  grayish 
deposit  on  the  inner  surface  of  the  dura.  This  deposit  is  detachable 
and  is  usually  studded  with  punctiform  hemorrhages.  The  dura  may 
be  slightly  distended.  Successive  layers  are  at  times  deposited,  making 
a  thick  membrane.  Oppenheim  says  that  the  milder  grades  of  the 
disease  may  accompany  any  chronic  inflammation  and  that  it  is 
common  in  senile  dementia,  chorea,  any  general  infection,  hemorrhagic 
disease,  alcoholism  or  injuries. 


INFLAMMATIONS  OF   THE  BRAIN  AND   THE  MENINGES    393 

Diagnosis. — ^A  probable  diagnosis  may  be  made  in  the  presence  of  one 
of  these  etiological  factors  accompanied  by  the  evidences  of  cortical 
irritation  and  followed  by  the  e^ddences  of  pressure,  but  lacking  the 
signs  of  acute  meningitis  with  its  cranial  nerve  involvement  and  spinal 
fluid  changes.  At  times  the  diagnosis  may  be  confirmed  by  finding 
blood  mixed  with  the  fluid.  The  picture  may  be  atypical  and  acute 
or  subacute. 

Treatment.- — In  a  majority  of  cases  the  treatment  wQl  consist  in 
sedatives,  and  the  local  use  of  an  ice  cap,  combined  with  elimination  by 
cathartics.  Xeisser  and  Pollock  have  reported  cures  by  their  method 
of  brain  puncture,  but  the  operation  surely  should  be  done  only  in 
exceptional  cases  or  not  at  all  since  the  danger  of  injury  to  the  pial 
vessels  is  too  great  to  be  overlooked.  In  severe  states  of  pressure  or 
prolonged  couMilsions,  a  decompression  operation  is  indicated. 
Repeated  lumbar  punctiu-e  gives  a  slight  measure  of  temporary  relief, 
and  in  mild  cases  may  be  of  benefit. 

The  treatment  of  post-traumatic  extravasations  and  allied  condi- 
tions leading  to  mental  changes  as  well  as  the  acuter  more  extensive 
meningeal  hemorrhages,  will  be  discussed  in  the  section  devoted  to 
traumatisms. 

Acute  tiflammation  of  the  Meninges. — We  shall  limit  our  discussion 
to  those  types  of  meningitis  of  especial  interest  to  the  surgeon  and 
speak  here  of  the  generalized  form,  reserving  for  the  section  upon 
abscess  and  localized  inflammations  the  discussion  of  pachymeningitis 
and  serous  meningitis. 

The  acute  inflammation  may  arise  in  the  course  of  an}^  of  the  acute 
systemic  diseases,  such  as  pneumonia,  influenza,  etc.,  or  may  be  due  to 
the  introduction  of  bacteria  through  traumatic  som-ces  or  by  extension 
from  a  local  suppurative  process  in  the  bones,  sinuses,  or  bloodvessels, 
adjacent  to  the  brain.  It  is  manifest,  therefore,  that  the  onset  may  be 
fulminating,  or  more  or  less  chronic  if  the  organism  be  avirulent,  or 
the  local  condition  present  the  possibility  of  plastic  exudate,  hindering 
the  rapid  spread  as  in  chronic  otitis  media.  In  the  more  explosive  form 
there  may  be  no  prodromal  sjTaptoms.  In  the  chronic  tj'pe  the  pro- 
dromal s;^Tnptoms  may  precede  the  tj'pical  signs  of  meningitis  by  many 
days,  consisting  of  malaise,  slight  headache,  etc.,  characterized  by  the 
patient  as  bilious  sjTnptoms.  The  tj'pical  sjTnptoms  of  extending 
leptomeningitis  may  be  characterized  as  toxic,  irritative,  and  para- 
lytic, and  the  diagnosis  is  made  upon  these  added  to  the  history  of  an 
etiological  factor,  the  findings  upon  lumbar  pimcture  and  physical 
examination.  Unfortunately  for  the  standpoint  of  surgical  relief,  we 
have  no  pathognomonic  early  symptoms.  Haines  has  emphasized  the 
rapid  increase  of  blood-pressure  and  edema  of  the  fundus. 

The  patient  complains  of  an  intractable  headache  incompletely 
relieved  by  morphin.  Exacerbations  are  noted  even  during  delirium; 
some  optic  neuritis  is  present  but  not  the  t^^ical  choked  disk;  vomiting 
is  frequent  but  not  constant.  The  patient  rapidly  passes  into  delirium, 
con^^lsions,  and  finally  coma.     Meanwhile,  the  fever  may  be  most 


394     TUMORS,   INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

variable,  being  high  or  even  subnormal  later.  The  pulse  may  be  fast 
or  slow.  The  urine  is  febrile  and  may  contain  sugar.  In  addition  to 
the  signs  of  cerebral  tension  and  irritation,  the  signs  of  nerve  irritation 
become  marked.  The  vision  may  become  dim  and  photophobia  appear. 
The  eye  muscles  may  become  spastic  or  paralyzed,  the  pupils  con- 
tracted early  and  later  dilated;  the  seventh  nerve  may  produce  mus- 
cular twitchings  in  the  face.  Irritation  of  the  sensory  nerves  produces 
hAr^eresthesia  of  the  skin  and  irritability  of  the  muscles;  of  the  motor 
nerves,  stiffness  of  the  neck,  abdominal  rigidity,  inability  to  extend  the 
leg  (Kernig)  or  flex  the  thigh  (Lasegue),  or  convulsive  seizures,  etc.; 
of  the  trophic  nerves,  herpes,  urticaria,  and  other  skin  eruptions  of  the 
vasomotor  nerves,  secretory  and  vasomotor  phenomena. 

Early  lumbar  puncture  will  show  little,  but  later  turbidity  produced 
by  polymorphonuclear  leukocytes  and  few  or  many  bacteria  will  be 
present — a  finding  which  should  not  be  awaited  if  we  expect  to  benefit 
the  patient  by  surgical  treatment. 

The  symptoms  of  acute  meningitis  may  be  produced  in  a  modified 
form  by  local  infective  processes  in  the  cranial  cavity  and  also  by  the 
toxemias  of  acute  infections;  e.  g.,  pneumonia,  tA^hoid,  septicemia, 
uremia,  delirium  tremens,  hysteria,  etc.  In  children  even  gastro- 
intestinal disorders  may  present  a  topical  picture,  except  for  the  phys- 
ical findings,  the  cerebrospinal  fluid  changes,  and  the  rapid  recovery 
following  catharsis.  It  should  be  noted  that  acute  otitis  media  espe- 
cially in  children  may  give  headache,  convulsions,  delirium,  stupor,  and 
even  a  paralysis  of  the  sixth  nerve  from  accompanying  edema. 

Treatment. — O^-ing  to  the  fact  that  little  can  be  expected  from 
treatment,  especial  care  should  be  used  in  prophylaxis.  This  consists 
in  asepsis  in  cranial  injuries  and  treating  otitis  media  and  various 
chronic  sinus  infections.  Some  clinicians  believe,  in  spite  of  experi- 
mental evidence  to  the  contrary,  that  the  administration  of  large  doses 
of  hexamethylamin  (gr.  xxx  to  xxxv)  every  few  hours  may  retard  infec- 
tion, and  the  author  has  used,  with  apparent  success,  antistreptococcus 
sera  in  50  c.c.  doses  as  a  prophylactic  in  certain  operative  procedures 
where  there  was  great  danger  of  such  infection. 

When  the  infection  has  once  started,  the  primary  focus  should  be 
treated  and  free  local  drainage  instituted.  Beyond  this  many  pro- 
cedures have  been  suggested  without  as  yet  demonstrating  any  positive 
benefit  in  severe  cases.  Many  milder  types  have  apparently  been 
cured  by  repeated  lumbar  puncture. 

Various  operative  procedures  having  for  their  purpose  drainage  or 
the  introduction  of  medicaments  have  been  suggested.  The  condition 
of  the  patient  is  not  impaired  by  these  and  a  certain  few  cases  have 
apparently  been  benefited.  The  repeated  intraspinal  injection  of 
hexamethylamin  (McKernon)  gr.  100  in  sterile  solution  in  such  concen- 
tration as  that  its  bulk  equals  one-half  of  the  amount  of  cerebrospinal 
fluid  removed  has  been  followed  by  a  few  recoveries.  Others  (Barr) 
have  introduced  a  needle  into  the  ventricles  and  injected  sterile  normal 
salt  or  antiseptic  solutions,  meanwhile  removing  fluid  by  lumbar 


INFLAMMATIONS  OF  THE  BRAIN  AND   THE  MENINGES    395 

puQcture;  this  has  not  as  yet  given  satisfactory  results  but  is  worthy 
of  further  study.  Haynes  has  suggested  drainage  by  way  of  the  cis- 
terna  magna.  An  incision  is  made  downward  from  the  occipital  pro- 
tuberance, and  the  tissues  retracted,  a  trephine  opening  is  made  one 
inch  below  the  protuberance  and  enlarged  by  the  rongeur  down  to  the 
foramen  magnum.  The  dura  and  arachnoid  are  opened  and  a  gutta- 
percha drain  inserted.  Day  and  others,  however,  have  not  had  success 
with  this  procedure. 

Barth  has  reported  the  recovery  of  three  cases  in  which  lumbar 
drainage  by  laminectomy  was  performed  and  Leighton  has  since 
reported  two  recoveries  by  the  same  procedure.  An  incision  is  made 
over  the  third  lumbar  vertebra  and  the  spines  and  laminae  of  the  third 
and  fourth  removed.  The  dura  is  opened  and  a  drain  inserted  down  to 
the  dura  and  the  muscles  sutured.  During  its  operation  the  head  is 
placed  at  a  lower  level  than  the  wound. 

Early  diagnosis  and  treatment  is  undoubtedly  a  strong  factor  in  the 
cure  and  at  the  present  time  a  thorough  eradication  of  the  focus  of 
infection  with  free  local  drainage  added  to  lumbar  drainage  would 
seem  to  offer  the  best  results,  and  it  is  possible  that  to  this  may  be 
added  intraspinal  urotropin  injections. 

Brain  Abscess. — Diagnosis.- — Abscess  of  the  brain  appears  in  one  of 
three  forms:  (a)  acute  fulminating;  (b)  latent;  (c)  stage  of  exacerba- 
tion. 

(a)  The  acute  fulminating  type  is  an  immediate  sequela  of  a  primary 
focus  still  present,  and  besides  the  focal  and  general  evidences  of  brain 
lesion  presents  to  a  marked  degree  the  signs  of  the  primary  focus  and 
the  evidences  of  inflammation,  e.  g.,  fever,  leukocytosis,  etc.  Here  the 
question  is  not  the  diagnosis  between  an  abscess  and  a  tumor,  but 
rather  the  diagnosis  from  an  extradural  or  intradural  abscess,  menin- 
gitis, both  purulent  and  serous,  and  the  primary  focus  itself.  This  is 
often  most  difficult  and  frequently  can  be  told  only  upon  operation. 

The  extradural  abscess  does  not  present  the  marked  focal  evidences 
frequently  present  in  the  abscess.  If  it  develops  from  an  otitis  media, 
there  is  often  pain  on  pressure  back  of  the  mastoid,  swelling  in  this 
region,  and  a  tendency  to  hold  the  head  in  a  fixed  position,  and  upon 
operation  such  an  amount  of  pus  is  evacuated  before  reaching  the 
brain  that  the  operator  concludes  that  the  pressure  may  have  come 
from  this. 

In  purulent  meningitis  we  have  the  presence  of  bacteria  and  leuko- 
cytes in  the  spinal  fluid.  The  evidences  of  a  more  difi^use  involvement 
of  the  entire  system  is  described  above. 

Sinus  thrombosis  is  considered  below. 

Subdural  abscess,  purulent  meningo-encephalitis,  is  to  all  intents 
and  purposes,  a  brain  abscess. 

Serous  meningitis  frequently  accompanies  an  otitis  media.  Here 
we  have  a  diffuse  involvement  with  an  early  optic  neuritis,  f  The 
symptoms  are  relatively  mild,  as  regards  temperature.  The  focal 
symptoms  are  generally  less  positive  and  persistent  than  in  abscess  and 


396     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

less  extensive  and  severe  than  in  purulent  meningitis.    It  should  be 
remembered  that  any  of  these  processes  may  accompany  an  abscess. 

(b)  Latent  Stage. — An  abscess  may  remain  for  many  years  and  pro- 
duce no  signs  whatever,  or  there  may  be  a  history  of  vague  symptoms, 
particularly  slight  headache,  some  impairment  of  vision  especially  upon 
careful  tests,  and  mental  deterioration,  noted  especiallv  as  hebetude 
(Fig.  183). 


Fig.  133. — Old  abscess  of  the  brain. 


(c)  Stage  of  Exacerbation. — ^This  may  appear  in  various  forms  from 
indefinite  evidences  to  positive  signs  of  brain  involvement  as  noted 
below.  Here  the  question  of  diagnosis  from  brain  tumor  immediately 
arises  and  we  search  for  a  history  of  a  primary  focus  and  the  evidences 
of  inflammation,  either  of  which  will  be  of  great  aid  in  the  diagnosis. 
Unfortunately  the  primary  focus  may  have  healed  years  before,  while 
the  encapsulation  and  a  toxicity  of  the  old  abscess  may  prevent  the 
development  of  the  evidences  of  inflammation. 

The  stage  of  exacerbation  is  prone  to  be  ushered  in  brusquely  in  one 
of  the  following  ways:  The  patient  may  begin  suddenly  to  complain 
of  headache  and  vomiting.  The  patient  seems  to  be  somewhat  apathet- 
ic, and  an  examination  of  the  eye  grounds  often  shows  a  retinitis, 
whether  due  to  pressure  or  to  toxemia  as  Lewandowsky  suggests,  may 
be  open  to  question,  but  the  frequent  absence  of  choked  disk  seems 
to  speak  for  the  latter.  Slow  pulse  is  frequently  present.  In  addition 
we  may  have  focal  symptoms  from  the  sites  of  predilection  of  abscess. 

The  occmrence  at  any  time  of  life  of  a  hemiplegia  which  starts  as 
a  monoplegia  and  requires  several  days  for  development,  if  accom- 
panied by  the  above  symptoms  and  particularly  if  signs  of  infla.mmation 
are  present,  is  very  suggestive. 


INFLAMMATIOXS  OF  THE  BRAIX  AXD   THE  MEXIXGES     397 

The  sudden  onset  of  comTilsions,  otherwise  imexpla'inable  and 
accompanied  by  fever,  very  strongly  suggests  abscess.  The  more  or 
less  sudden  development  of  aphasia  or  monoplegia  in  a  patient  with  a 
history  of  otitis  warrants  in  a  majority  of  cases  the  diagnosis  of  an 
abscess. 

Given  any  one  of  the  groups  of  symptoms,  the  diagnostician  imme- 
diately searches  for  confirmatory  e\'idences  as  found  in  (a)  sign  of 
inflammation,  (b)  primary  focus,  (c)  focal  signs. 

As  has  been  said  fever  and  leukocytosis  may  be  absent  in  fully  a 
third  of  the  cases,  and  when  present  they  are  generally  moderate  in 
degree.  A  high  fever  generally  indicates  either  acuteness,  impingement 
of  the  abscess  upon  the  meninges  or  ventricles,  or  rupture  into  them. 
Chills  may  be  present. 

The  most  common  source  of  abscess  is  the  middle  ear,  but  the  abscess 
may  arise  from  a  nasal  sinus  or  from  orbit  disease,  from  any  other 
focus  about  the  skull,  or  from  a  metastatic  source.  The  nasal  sinus  or 
orbit  naturally  give  rise  to  frontal  abscesses,  the  roof  of  the  t^TQpanic 
cavity  or  of  the  mastoid  to  temporal,  and  the  mastoid  process  and 
labjTinth  to  cerebellar  abscesses.  Metastatic  abscesses  locate  along 
the  Syhian  fissure. 

Focal  SATuptoms  may  be  entirely  lacking,  especially  in  the  frontal 
and  right  temporal  lobes.  The  left  temporal  may  give  rise  to  partial 
or  complete  word  deafness,  amnesia,  or  paraphasia.  If  the  abscesses 
are  large  or  deep,  they  press  on  the  motor  and  sensory  zones  with 
corresponding  signs.  "When  arising  from  the  ear,  they  frequently  lie 
near  the  base  and  may  give  rise  to  basal  nerve  signs,  especially  the 
third  and  sixth. 

For  a  complete  discussion  of  focal  signs  in  the  various  regions,  the 
reader  is  referred  to  that  section  in  the  early  portion  of  the  chapter, 
since  they  differ  in  nowise  from  those  found  in  tumors. 

Treatment. — Since  about  a  third  of  the  abscesses  of  the  brain  follow 
infected  injuries  and  a  considerable  proportion  of  the  remainder  have 
their  origin  in  otitis  media  especially  of  the  chronic  type,  especial 
prophylactic  care  should  be  directed  to  these  conditions. 

When  there  is  no  evidence  of  a  primary  focus  and  no  localizmg  signs 
can  be  elicited,  we  should  remember  that  by  far  the  largest  number  of 
abscesses  are  found  in  either  the  temporosphenoidal  lobes  or  the  cere- 
bellum. They  may,  however,  be  found  in  the  frontal  lobe  from  nasal 
or  orbital  disease,  along  the  Sylvian  fissure,  from  metastatic  foci,  the 
occipital  lobe,  or,  indeed,  any  part  of  the  brain.  Statistics  would  seem 
to  show  that  60  per  cent,  of  the  abscesses  are  in  the  temporosphenoidal 
lobe,  25  per  cent,  in  the  cerebellum,  and  15  per  cent,  in  the  frontal  lobe 
and  other  parts  of  the  cerebrum.  Ballance  has  suggested  that  in  sus- 
pected abscesses  with  nothing  to  suggest  a  location,  we  should  make 
a  good-sized  decompression,  open  the  dura  by  the  flap  method,  and 
pack  the  area  under  the  edges  of  the  dura  for  one  or  two  days  for  the 
purpose  of  producing  limiting  adhesions  and  faA'oring  the  adi'ance  of 
the  abscess  toAvard  the  surface — a  procedure  that  has  much  to  recom- 


398     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

mend  it  in  certain  cases.  In  whatever  portion  of  the  brain  we  attack 
we  should  remember  that  the  abscesses  tend  to  he  in  the  white  matter, 
owing  to  the  fact  that  it  is  more  easily  liquified  than  the  neuroglia- 
bound  cortex  upon  which  the  abscess  is  prone  to  impinge,  however, 
and  hence  seldom  lies  deeper  than  an  inch.  Again,  the  abscesses  tend 
to  lie  in  juxtaposition  to  the  site  of  origin.  Thus  frontal  abscesses  most 
frequently  lie  in  the  inferior  frontal  convolution;  the  temporosphenoidal 
in  the  inferior  convolution  near  the  petrous  portion  of  the  temporal 
bone;  the  cerebellar  in  the  lateral  lobe  near  the  same  bone;  while  the 
metastatic  lie  near  the  Sylvian  fissure.  Ballance  has  dra-wTi  attention 
to  the  so-called  "stalk,"  a  connective  tissue  sinus-like  connection 
between  the  abscess  and  the  site  of  entry.  When  this  is  found  it  is  a 
valuable  guide  in  locating  the  abscess.  Owing  to  the  fact,  however, 
that  most  unlocalized  abscesses  are  approached  from  the  external 
surface  and  these  "  stalks"  come  off  from  the  petrous  portion  of  the  bone 
on  the  basal  portion,  they  are  not  frequently  found  at  operation, 
except  by  the  otologist  who  searches  for  the  abscess  by  way  of  the  ear. 
jNIuch  controversy  is  found  as  to  the  proper  technic  to  be  used  in  search- 
ing for  the  abscess.  Lately  Sharpe  has  advised  large  osteoplastic  flaps 
over  the  temporal  or  cerebellar  regions,  not  alone  for  more  adequate 
investigation,  but  also  to  guard  against  the  ill  effects  of  consequent 
brain  edema.  If  Sharpe's  method  is  followed  a  muscle-splitting  opera- 
tion should  be  done  to  prevent  hernia,  since  if  the  abscess  is  found, 
drainage  must  be  instituted.  It  probably  is  true,  at  least,  that  the  small 
trephine  openings  advocated  by  some  are  frequently  inadequate. 
Again,  there  is  much  debate  as  to  whether  the  dura  should  be  cut  in 
flap  form,  the  subdural  space  walled-off,  and  the  abscess  sought  for  at 
the  time  or  after  a  day  or  two,  or  whether  multiple  small  cuts  should 
be  made  through  the  dura  and  the  punctures  made  through  these. 
The  latter  has  much  to  recommend  it  in  cases  where  there  is  consider- 
able doubt  as  to  the  diagnosis.  Puncture  through  the  unopened  dura 
should  never  be  done  owing  to  the  possibility  of  injury  to  the  pial 
vessels. 

The  pus  is  generally  thick;  therefore,  if  a  needle  is  used  it  should  have 
a  2  mm.  aperture  at  least.  Ballance  and  others  recommend  a  knife, 
but  most  surgeons  prefer  a  large  needle,  groove  director,  or  preferably  a 
searcher  of  small  size  that  has  two  blades  which  may  be  separated, 
allowing  the  pus  to  escape  between  the  blades.  Page  and  others  have 
devised  and  described  such  forceps  (Fig.  134).  Having  found  the 
abscess,  the  pus  should  be  allowed  to  escape  freely.  Krause  inserts  his 
finger  and  breaks  up  the  loculi,  a  procedure  that  in  most  cases  is  not 
advisable,  but  if  it  were  done  would  probably  lead  to  detection  of 
secondary  abscess  if  they  were  present.  It  goes  without  saying  that 
the  subdural  space  should  be  well  walled-off  by  gauze  if  limiting 
adhesions  are  not  present.  Gutta  percha  or  cigarette  drains  should 
be  inserted,  and  in  the  chronic  cases  should  be  left  in  for  a  considerable 
period.  One  case  coming  under  the  author's  observation  was  drained 
three  times  with  ultimate  recovery,  a  multiplicity  of  operations  which 


INFLAMMATIONS  OF   THE  BRAIN  AND   THE  MENINGES     399 

would  have  been  avoided  if  the  drain  had  been  left  in  place  longer — a 
procedure  which  necessitates  suturing  the  drain  to  the  skin  or  dura. 

With  these  general  principles  considered,  let  us  ask  ourselves  what 
should  be  our  method  of  attack  in  a  given  case.  While  considerable 
difference  of  opinion  exists  as  to  the  proper  procedure,  it  has  seemed 
to  the  author  that  the  following  may  be  considered  as  a  working  basis. 

1.  In  chronic  cases  icith  no  localizing  signs  or  evidences  of  primary 
focus,  a  large  subtemporal  muscle-splitting  decompression  with  cutting 
of  the  dura  may  be  done,  and  the  undersurface  of  the  dural  edge 
traumatized  or  packed  lightly  with  gauze  to  produce  adhesions  after 
the  Ballance  method.  The  opening  should  be  adequate  and  go  well 
down  on  the  temporal  bone  so  as  to  expose  the  first  temporal  convolu- 
tion. Its  greatest  diameter  should  be  anteroposterior  to  give  ample 
field  for  puncture  in  various  directions.  The  frontal  or  cerebellar 
regions  may  be  similarly  exposed  when  desired. 


Fig.   134. — Page  pus  searcher. 


2.  Acute  Processes  with  Suspected  Abscess. — ^Let  us  suppose  the 
process  to  be  an  acute  otitis  media.  As  stated  above  the  diagnosis  is 
difiicult  and  we  may  be  in  doubt  as  to  whether  we  are  dealing  with  an 
otitis  alone  or  otitis  complicated  with  an  extradural  abscess,  a  sinus 
thrombosis,  serous  meningitis,  subdural  abscess,  or  an  intracerebral 
or  intracerebellar  abscess.  The  condition  of  the  patient  in  any  case 
will  be  such  as  to  demand  expeditious  operation.  Therefore,  our 
operation  should  be  so  planned  as  to  meet  these  possibilities.  We  have 
three  courses  open:  (1)  we  may  begin  with  the  ear,  open  the  mastoid, 
antnun,  and  ear,  and  then  proceed  directly  to  the  cerebrum  or  cere- 
bellum as  the  diseased  bone  may  suggest;  (2)  after  opening' the  mastoid 
we  may  make  a  second  trephine  opening  over  either  the  temporo- 
sphenoidal  lobe  or  the  cerebellum;  (3)  after  opening  the  mastoid  we 
may  make  the  opening  over  the  sigmoid  sinus  and  enlarge  the  opening 
both  upward  to  expose  the  temporosphenoidal  lobe  and  downward  and 
backward  to  expose  the  cerebellum.  In  a  majority  of  the  acute  cases, 
it  is  wiser  to  proceed  directly  from  the  ear,  in  which  case  the  technic 
is  as  follows:  The  mastoid  and  ear  having  been  cleaned  out  rapidly 
without  attention  to  minor  details,  the  wall  is  examined  for  caries.    If 


400     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

the  wall  of  the  tegmen  or  the  anterior  surface  of  the  petrous  bone  are 
destroyed,  it  suggests  extradural  abscess  here  or  temporosphenoidal 
abscess;  if  over  the  vestibule  or  the  internal  auditory  meatus  the  cere- 
bellum is  suspected  or  both,  they  may  be  examined  if  desu-ed.  If  the 
posterior  fossa  is  suspected  the  bone  is  removed  over  the  sinus;  if 
extradural,  pus  is  evacuated.  This  may  be  all  that  is  necessary.  The 
sinus  is  palpated  and  inspected.  If  still  unsatisfied,  two  routes  are 
available;  viz.,  to  the  inner  or  outer  side  of  the  sinus.  Infection  from 
the  antrum  may  produce  a  lateral  sinus  thrombosis,  or  pass  internal 
through  the  dura  mater.  Infection  from  the  lab^-rinth  may  pass 
between  the  semicircular  canals  and  destroy  the  posterior  wall  of  the 
petrous  portion  or  may  pass  into  the  internal  auditory  meatus  and 
along  the  seventh  or  eighth  nerves  to  the  deeper  part  of  the  cerebellum. 
By  going  to  the  anterior  side  of  the  sinus  we  have  a  more  direct  path  in 
case  the  abscess  lies  deep.  Special  care  should  be  used  not  to  injure 
the  facial  nerve.  The  outer  or  posterior  route  gives  more  dependent 
drainage  and  is  in  a  less  infected  field  but  the  abscess  is  more  likely  to 
be  missed.  In  the  inner  or  anterior  route,  the  posterior  bony  wall  of 
the  ear  operation  field  is  removed,  laying  bare  the  inner  margin  of  the 
lateral  sinus.  The  dura  is  raised  and  the  field — a  very  small  triangle — 
exposed,  bounded  by  the  facial  ner^'e  and  the  sinus,  a  dangerous  area 
for  one  not  intimately  acquainted  with  aural  surgery.  The  dura  is 
cut  horizontally  keeping  the  edge  of  the  sinus  in  view.  The  exploring 
needle  is  passed  backward,  inward,  and  slightly  upward.  By  the 
outer  route  which  is  somewhat  easier,  an  incision  is  made  transversely 
backward  from  the  original  skin  incision .  The  scalp  tissues  are  elevated 
and  the  bone  removed,  exposing  the  sinus  and  going  backward  until 
the  dura  below  is  exposed  for  at  least  an  inch  in  each  direction.  The 
incision  of  the  dura  is  parallel  with  the  sinus  and  below  it.  The  cere- 
bellum is  now  explored  by  passing  the  ex^Dloring  needle  inward  and 
slightly  upward,  since  the  abscess  lies  near  the  anterior  surface  of  the 
lateral  lobe.    If  found,  drainage  is  instituted  as  described  above. 

If  the  destruction  of  bone  suggests  the  temporosphenoidal  lobe,  or 
if  for  any  other  reason  it  is  desired  to  explore  the  lobe  from  the  ear,  one 
proceeds  as  follows:  The  roof  of  the  operation  cavity  is  removed, 
going  inward,  upward  and  foru'ard.  If  no  extradural  abscess  is  found, 
the  dura  is  incised.  The  presence  of  serous  meningitis  may  explain  all 
of  the  symptoms,  but  on  the  other  hand  such  a  meningitis  often  accom- 
panies an  abscess.  The  exploring  needle  is  pushed  upward  for  three- 
fourths  of  an  inch;  if  no  pus  is  found  it  is  inserted  forward  and  upward, 
and  then  backward  and  upward.  Do  not  go  too  deeply  since  the  abscess 
is  generally  near  the  surface  in  the  inferior  lobe. 

^Vhenever  the  dura  is  to  be  opened,  the  field  should  be  cleaned  as 
well  as  possible,  painted  with  tincture  of  iodine,  and  if  space  permits, 
the  subdural  space  around  the  edges  packed  with  gauze.  If  only  a 
small  incision  is  made  in  the  dura,  the  brain  bulges  into  the  cut  so  as 
to  practically  obliterate  the  spaces. 

In  the  second  method,  after  cleaning  out  the  ear  and  mastoid,  search 


INFLAMMATIONS  OF  THE  BRAIN  AND   THE  MENINGES    401 

of  the  temporosphenoidal  lobe  from  a  separate  opening  is  carried  out 
by  one  of  two  ways :  either  the  skin  incision  abeady  made  may  be  con- 
tinued upward  and  forward  to  expose  an  area  one  inch  in  diameter, 
the  central  point  of  which  is  one  inch  above  the  posterior  margin  of  the 
external  auditory  meatus,  or  we  may  use  a  small  subtemporal  muscle- 
splitting  operation  over  the  inferior  temporosphenoidal  lobe. 

If  we  wish  to  enter  the  cerebellum  by  a  separate  opening,  a  line  is 
drawn  from  the  occipital  protuberance  to  the  external  auditory  meatus 
and  a  trephine  opening  is  made  1  cm.  below  this  line  and  3|-  cm. 
behind  the  auditory  meatus.  The  bone  opening  is  enlarged  as  necessary. 
The  dura  is  opened  and  the  brain  explored  as  described  above. 

If  the  third  method  is  chosen,  after  the  ear  and  mastoid  have  been 
cleaned  out,  the  bone  may  be  cleared  off  and  a  trephine  entered  one 
inch  behind  and  one-quarter  inch  above  the  external  auditory  meatus. 
This  will  expose  the  sinus.  By  removing  bone  above  and  anteriorly 
the  temporosphenoidal  lobe  may  be  reached,  and  by  removing  it  down- 
ward and  backward  the  cerebellum  may  be  reached. 

3.  In  chronic  cases  with  a  primary  focus  present,  the  same  three 
courses  of  treatment  are  open  as  above.  There  is  some  slight  advantage 
in  opening  the  two  fields  separately  since  if  no  abscess  is  found  there  is 
less  danger  of  infection;  on  the  other  hand,  by  operating  through  the 
ear  there  is  greater  probability  of  identifying  the  "stalk"  mentioned 
and  thus  following  it  to  its  source. 

4.  In  chronic  cases  with  localizing  signs  without  a  'primary  focus  being 
present,  either  a  one-  or  two-stage  operation  may  be  done.  The  latter 
is  certainly  safer  and  where  delay  is  not  dangerous  is  worthy  of  con- 
sideration. In  either  case  the  area  is  reached  by  one  of  the  extradural 
routes  mentioned  above  for  the  indi\'idual  lobes. 

In  Korner's  series  of  212  temporosphenoidal  abscesses,  the  best 
results  were  obtained  when  the  abscess  was  opened  by  the  mastoid 
route,  and  by  direct  trephining  of  the  skull;  the  next  best  by  opening 
through  the  mastoid  route ;  while  the  poorest  results  came  from  direct 
trephining  without  operation  on  the  mastoid. 

If  good  results  are  to  be  obtained  in  the  treatment  of  brain  abscesses 
the  surgeon  must  be  prepared  to  operate  on  evidence  which  amounts 
to  much  less  than  certainty  and  expect  to  fail  in  finding  the  abscess  in 
a  certain  nimiber  of  cases. 

Thrombosis  of  Intracranial  Blood  Sinuses. — Diagnosis. — ^These  pre- 
sent the  evidences  of  obstruction  to  the  return  of  blood  through  the 
afferent  veins,  and  if  the  process  is  an  infectious  one,  the  symptoms  of 
local  inflammation  and  general  septic  phenomena.  From  a  surgical 
standpoint  thrombosis  of  the  lateral  and  cavernous  sinuses  is  most 
important  particularly  the  former,  although  the  longitudinal  and  other 
sinuses  may  be  involved. 

When  the  cavernous  sinus  is  the  seat  of  thrombo-sinusitis,  we  have 
cyanosis  of  the  orbital  and  the  frontal  regions  with  protrusion  of  the 
eyeball.  Pain  along  the  first  branch  of  the  fifth  nerve  may  be  present 
with  possible  paralysis  of  the  third,  fourth,  and  sixth.    To  these  signs 

VOL.  1—26 


402     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

are  added  the  fever,  leukocytosis,  chills,  etc.,  associated  with  sepsis. 
When  the  lateral  sinus  is  involved,  the  origin  is  frequently  from  an 
otitis  media.  We  will  therefore  commonly  have  the  evidences  of  this 
disease  and  superimposed  upon  it  the  signs  of  occlusion  of  its  afferent 
vessels,  producing  headache,  edema  posterior  to  the  ear,  dilatation 
of  the  cutaneous  veins;  secondly  the  signs  of  local  infection,  as  tender- 
ness; thirdly,  the  local  and  general  evidences  of  extension  of  the  clot 
down  the  jugular  vein,  with  tenderness  in  the  neck,  torticollis,  and  the 
cordlike  feeling  of  the  vessel  due  to  the  clot  therein;  fourthly,  the  evi- 
dences of  sepsis,  with  chills,  fever,  and  the  signs  of  extension  of  the 
septic  process  into  the  lungs;  fifthly,  the  effect  upon  the  nerves,  since 
at  times  the  ninth,  tenth,  eleventh  and  twelfth  may  be  involved  and 
paralysis  ensue.  It  is  seen,  therefore,  that  early  the  signs  may  simulate 
an  extradural  abscess,  or  brain  abscess,  since  the  impaired  circulation 
may  produce  a  choked  disk,  vertigo,  vomiting,  slow  pulse,  stupor,  excita- 
bility, etc.,  with  the  signs  of  infection.  If  the  signs  of  pyemia  develop 
with  involvement  of  the  jugular,  the  diagnosis  is  clear.  Operation, 
however,  should  be  performed  early  before  these  complications  develop. 

Treatment. — If  we  hope  to  aid  these  cases,  the  operation  should 
be  done  before  the  stage  of  sepsis.  Therefore,  in  the  lateral  sinus  cases 
we  should  give  prompt  attention  to  any  evidence  of  extension  from  an 
otitis  media,  the  operation  being  planned  to  care  for  any  complication 
that  may  be  piesent,  whether  an  abscess  or  a  sinus  thrombosis,  and  we 
should  be  guided  by  the  findings  as  the  operation  progresses.  If  the 
extension  to  the  jugular  is  evident  or  pyemia  develops,  the  attack 
may  then  be  made  directly  upon  the  sinus  or  the  jugular  vein  as  the 
case  seems  to  demand.  In  connection  with  the  consideration  of  the 
technic  in  these  cases,  the  section  upon  brain  abscess  should  be  noted. 
Jones  recently  collected  from  English  surgeons  the  various  opinions  as 
to  the  procedure  in  these  cases,  and  correlated  them  as  follows : 

In  every  case  of  temporal  bone  disease  with  symptoms  suggesting 
the  presence  of  a  perisinus  abscess  or  the  onset  of  pyemia,  expose  the 
sigmoid  sinus  with  the  least  possible  disturbance  to  its  walls  until 
healthy  wall  is  seen  and  the  blood  in  the  part  is  judged  to  be  fluid  and 
the  lumen  controllable.  This  may  in^'olve  removing  bone  up  to,  or 
even  including,  the  covering  of  the  torcular  herophili,  and  down  to 
within  reach  of  the  jugular  foramen.  If  no  disease  is  apparent  except 
the  extradural  abscess  and  the  so-called  "healthy"  granulations  spring- 
ing from  the  sinus  wall,  and  if  only  one  rigor  has  been  observed — 
wait.  If  the  pyemia  is  established  but  not  severe  and  there  is  a  limited 
occluding  clot  in  the  sigmoid,  compress  above  and  below  clot,  remove 
clot,  excise  outer  wall  between  the  compresses,  and  pack  with  gauze. 
If  the  sinus  is  obviously  diseased,  but  contents  are  partly  fluid  and 
systemic  symptoms  marked,  expose  the  internal  jugular  vein  in  the 
neck.  Even  if  the  sinus  is  not  obviously  diseased,  and  the  blood  is 
fluid,  and  there  is  severe  pyemia  or  symptoms  of  bulb-thrombosis, 
expose  the  internal  jugular  vein,  occlude  both  sinus  and  vein,  drain, 
and  plug  the  intervening  part.  If  the  sinus  is  clotted  and  the  lower 
limit  of  diseased  wall  or  clot  cannot  be  reached,  expose  the  xe'm  in  the 


INFLAMMATIONS  OF  THE  BRAIN  AND   THE   MENINGES    403 

neck — this  is  merely  applying  the  principle  of  exposing  healthy  wall 
beyond  each  end  of  the  clot  without  undertaking  the  much  longer  and 
generally  unnecessary  operation  of  exposing  the  bulb.  Having  laid 
bare  the  internal  jugular  vein  at  the  entry  of  the  common  facial  vein, 
we  have  several  courses  to  consider.  If  the  vein  is  of  normal  size  and 
looks  healthy,  and  if  blood  is  flowing  freely  through  it,  compress  tem- 
porarily and  remove  the  clot  from  the  sinus  down  to  the  jugular 
foramen;  if  there  is  a  free  flow  of  blood  into  the  sinus,  plug  the  sinus 
after  draining  and  either  close  the  neck  wound  or  put  in  Voss'  pro- 
visional ligatures,  according  to  the  severity  and  duration  of  the  systemic 
symptoms.  If  the  vein  is  collapsed  above  the  facial,  but  healthy  and 
full  of  fluid  blood  below,  tie  in  two  places  and  divide  above  the  facial, 
bring  the  upper  end  into  the  wound,  and  endeavor  to  clear  out  the  clot 
from  the  bulb  by  gentle  irrigation.  The  same  procedure  can  be  adopted 
if  the  upper  vein  is  clotted  but  the  clot  does  not  reach  to  the  facial  vein 
and  the  lower  vein  is  healthy.  It  is  easier  to  clear  the  bulb  under  these 
circumstances  than  to  do  so  when  the  vein  is  collapsed. 

-When  the  clot  extends  beyond  the  facial  junction  it  is  better  to  tie 
and  divide  the  internal  jugular  as  low  down  as  possible  in  the  neck. 
Having  dissected  up  the  vein  and  tied  off  the  tributaries  including  the 
facial,  excise  the  greater  part  and  bring  the  upper  end  into  the  wound. 
There  is  always  a  temptation  to  leave  the  vein  unopened  the  first  day, 
for  fear  of  severe  hemorrhage,  but  the  risk  of  extension  of  sepsis  from 
the  upper  vein  is  too  great,  and  drainage  from  sinus  to  vein  should  be 
established  at  once.  The  wound  in  the  neck  may  be  closed,  except 
the  upper  inch  without  packing,  unless  the  walls  of  the  vein  are  dis- 
eased, though  the  danger  of  suppiu*ation  along  the  trachea  is  a  real 
.  one.  Associated  cerebral  and  cerebellar  abscess,  meningitis,  metastatic 
abscesses  must,  of  course,  be  dealt  with  as  occasion  demand. 

The  ayyroach  to  tJie  caverncus  sinus  may  be  laterally  by  way  of  the 
middle  fossa,  through  the  orbit,  or  through  the  nose.  The  former 
would  be  used  in  exceptional  cases  only.  Mosher  has  described  a 
method  of  draining  the  sinus  through  the  orbit  as  follows: 

The  eye  and  the  orbital  contents  are  removed,  the  ophthalmic  artery 
tied,  the  periosteum  cleaned  from  the  posterior  half  of  the  floor  of  the 
orbit,  and  the  groove  recognized  in  which  the  superior  maxillary  nerve 
runs.  The  periosteum  is  now  separated  from  the  orbital  surface  of  the 
great  wing  of  the  sphenoid,  and  the  outer  end  of  the  sphenoidal  fissure 
recognized.  Now  place  the  chisel  A'ertically  and  make  a  cut  through 
the  great  wing  of  the  sphenoid  from  the  notch  for  the  superior  maxillary 
nerve  to  the  outer  end  of  the  sphenoid  fissure  above.  Enlarge  the 
opening,  making  the  lower  level  of  the  bone  window  on  a  level  with  the 
floor  of  the  orbit.  Elevate  the  dura  from  the  floor  of  the  middle  fossa, 
the  outer  wall  of  the  sinus  being  exposed,  place  a  blunt-pointed  knife 
against  the  sinus  on  a  level  with  the  floor  of  the  orbit  and  carry  the 
knife  toward  the  body  of  the  sphenoid,,  thus  opening  the  sinus. 

To  those  familiar  with  intranasal  surgery,  the  following  route  will 
probably  be  found  more  satisfactory. 

Langworthy  has  proposed  an  operation  as  follows :   Light  ether  vapor 


404     TUMORS,  INFLAMMATIONS  AND  ABSCESSES  OF  BRAIN 

anesthesia.  Plugging  of  posterior  nares  on  one  side  and  free  injection 
of  adrenalin  chloride  solution  about  the  operative  region.  Quick 
removal  of  obstructing  ethmoid  labyrinth,  middle  turbinate,  and  ante- 
rior sphenoidal  wall,  by  the  use  of  ethmoid  curette,  turbinate  forceps, 
sphenoidal  curette,  punch,  and  long  narrow-handle  gouge  and  hammer. 
Once  in  the  sphenoid  cavity  the  author's  straight  and  angular  blunt 
curettes  with  overhanging  edge  can  be  pushed  through  the  roof  of  the 
sphenoidal  sinus  close  to  the  junction  of  its  roof  and  external  wall. 
The  blunt  ends  of  these  curettes  will  push  the  carotid  artery  aside 
without  damage  and  by  rotating  the  spoon  in  a  forward  direction  away 
from  the  carotid  artery  the  overhanging  edge  of  the  curette  catches 
bone  and  a  hole  of  some  size  can  be  made  leading  directly  into  the  sinus. 
This  can  be  further  enlarged  by  use  of  curettes  assisted  as  mentioned 
by  a  long  narrow  chisel  and  hammer.  The  chief  danger  of  the  opera- 
tion here  I  would  say  is  not  quite  so  much  the  thick-walled  large 
carotid  artery  but  rather  some  unexpected  small  branches  given  off 
frequently  in  this  region  which  when  accidentally  torn  by  instrumenta- 
tion might  prove  troublesome — ^much  of  this,  however,  is  at  present 
pure  speculation. 

Tuberculous  Meningitis.— Diagnosis.— The  diagnosis  must  be  made 
on  the  evidences  of  a  meningitis  developing  more  slowly  than  the  acute 
meningitis,  the  presence  of  a  possible  source,  the  age  of  the  patient, 
and  the  findings  in  the  cerebrospinal  fluid.  The  disease  is  found  most 
often  in  children  who  are  poorly  nourished.  There  is  frequently  a 
prodromal  stage  of  restlessness  and  sleeplessness  followed  by  headache. 
In  a  week  to  a  month  the  evidences  of  meningitis  appear,  with  muscular 
twitchings,  cranial  nerve  involvement,  and  finally  delirium,  coma, 
paralysis,  etc.  Variable  temperature  is  present  and  the  spinal  fluid 
is  clear  with  a  lymphocyte  increase;  in  exceptional  cases  the  spinal 
fluid  may  be  purulent  or  bloody;  deceptive  remissions  occur. 

Treatment. — Operative  treatment  such  as  decompression,  repeated 
lumbar  puncture,  etc.  have  been  tried,  but  without  influencing  the 
course  of  the  disease.  It  hydrocephalus  follows  it  may  be  treated  by 
corpus  callosum  puncture. 

Syphilis  of  the  Brain. — The  protean  picture  presented  by  syphilis 
of  the  bram  is  the  cause  of  failure  in  diagnosis  by  the  novice  and  the 
most  suggestive  factor  in  diagnosis  to  the  expert.  This  is  due  particu- 
larly to  the  many  forms  the  disease  may  take,  from  a  simple  meningitis 
to  arterial  changes  and  their  consequences,  or  even  to  solitary  or 
multiple  intracerebral  manifestations.  They  may  occur  as  early  as 
three  or  four  weeks  or  as  late  as  many  years  after  infection,  while 
isolated  gummata  may  appear  indistinguishable  in  symptomatology 
from  brain  tumor  except  for  the  serological  findings.  There  is  most 
often  an  atypical  picture  involving  both  brain  and  spinal  cord.  In 
almost  all  cases  where  present  the  disease  may  be  suspected  and  must 
be  confirmed  by  the  Wassermann  reaction,  before  absolute  diagnosis 
is  possible.  Among  the  suggestive  symptoms  are  headache,  motor 
disturbances,  cranial  nerve  involvements,  spinal  complications,  dis- 
orders of  sleep,  alterations  of  character,  and  sensory  phenomena.    It  is 


INFLAMMATIONS  OF  THE  BRAIN  AND   THE  MENINGES    405 

evident  that  these  are  not  peculiar  to  brain  syphiHs,  and  yet  a  careful 
study  of  them  may  be  suggestive.  The  headache  is  often  most  severe, 
being  described  as  throbbing,  boring,  etc.,  it  is  recurring  and  fau-ly 
constant,  and  mav  be  the  only  symptom  or  may  be  associated  with 
vomiting,  dizziness,  and  choked  disk,  especially  in  gummata,  and  in 
cases  where  no  assignable  cause  can  be  found  for  such  a  headache, 
serological  tests  should  be  made  of  both  the  blood  and  spinal  fluid. 
Motor  disturbances  are  fairly  common,  varying  from  a  Jacksonian 
epilepsy  seen  with  gumma,  to  twitching,  spasms,  localized  and  atypical 
paralysis.  Hemiplegia  is  not  uncommon  and  when  it  does  occur  before 
the  natural  age  and  without  high  blood-pressure  is  suggestive.  The 
cranial  nerve  most  often  involved  is  the  third,  but  any  others  may  be 
so  affected,  especially  the  fourth  and  sixth.  Alterations  of  character 
may  be  marked :  the  active  may  become  sluggish;  the  thrifty,  profligate; 
the  moral,  immoral;  or  less  prominent  characteristics  changed. 

Insomnia  is  a  very  common  complaint  and  when  found  should  lead 
to  investigation. 

The  sensory  changes  are  most  variable  but  a  rather  constant  symp- 
tom of  brain  sj^Dhilis. 

Treatment. — The  treatment  of  brain  syphilis  calls  for  most  persistent 
attention.  The  common  belief  that  potassium  iodide  has  any  curative 
value  in  the  condition  should  be  discounted.  It  does  give  relief  to 
symptoms,  and  may  cause  a  recession  of  the  gummatous  and  syphilitic 
deposit,  but  does  not  act  to  destroy  the  spirochetse.  For  this  purpose 
either  arsenic  or  mercm-y  are  necessary  and  at  times  the  administration 
of  both  will  be  of  advantage.  The  mercury  should  be  given  in  large 
doses  and  persistently.  There  is  nothing  superior  to  the  rubbings  with 
blue  ointment,  but  the  deep  muscular  injections  in  various  forms  are 
also  efficacious.  Salvarsan  either  intravenously  or  intraspinally  may 
be  given.  It  is  thought  by  Hall  and  others  that  dissolving  the  drug  in 
the  aspirated  cerebrospinal  fluid  and  reinjecting  it  into  the  subdural 
space  may  produce  better  results.  This  should  be  repeated  frequently 
and  is  best  supplemented  by  mercury  treatment.  The  treatment  should 
be  continued  until  the  Wassermann  remains  negative  for  at  least  a 
year,  and  it  is  wise  to  make  subsequent  tests  and  keep  the  patient 
under  observation  for  a  number  of  years.  Hamill  who  has  had  con- 
siderable experience  in  the  treatment  of  cerebrospinal  syphilis  sum- 
marizes his  views  as  follows:  Syphilis  of  the  nervous  system  is  to  be 
treated  as  syphilis  whether  early  or  late.  If  early  intravenous  methods 
probably  suffice,  but  they  must  be  controlled  by  Wassermann  on  the 
blood  and  spinal  fluid.  The  method  producing  the  most  favorable 
results  is  an  intermittent  one:  three  or  four  injections  at  four-  to  seven- 
day  intervals,  two  or  three  months  of  rest  with  intramuscular  injections 
of  mercury  and  then  another  and  even  a  third  series.  Late  nervous 
syphilis  should  receive  both  intravenous  and  local  treatment,  if  we 
may  so  term  subdural  injections. 

In  those  cases  presenting  persistent  brain  pressure  symptoms, 
threatening  loss  of  sight,  a  subtemporal  decompression  or  puncture  of 
the  corpus  callosum  may  be  indicated. 


THE  PUEPOSE  AND  TECHXICAL  STEPS  OE  A 
SUBTEMPORAL  DEC03IPRESSI0X; 

By  HARVEY  GUSHING,  M.D. 

The  ^■iew,  long  held  by  some  neurologists,  that  mtracranial  tumors 
are  of  far  more  frequent  occurrence  than  the  usual  morbidity  figures 
would  indicate,  has,  during  the  past  decade,  come  to  be  generally 
accepted.  That  the  profession  has  been  slow  to  appreciate  this  is  not 
to  be  wondered  at,  for  few  have  been  trained  along  neurological  lines, 
and  even  those  who  were,  have  hesitated  to  make  a  diagnosis  of  tumor 
unless  the  so-called  classical  features  of  an  advanced  process  were 
present. 

When,  however,  under  the  caption  of  "brain  tumors,"  we  include 
growths  not  only  of  the  encephalon  but  also  of  its  meningeal  coverings 
and  of  its  appendages,  choroid  plexus,  pituitary  and  pineal  bodies,  the 
s\Tiiptoms  which  may  be  evoked  are  diverse  in  the  extreme,  and,  indeed, 
there  may  be  no  appreciable  symptoms  whatsoever  until  late  in  the 
course  of  the  disorder  and  even  then  unclassical  ones.  For,  regarded 
broadly,  intracranial  tumors  are  of  most  varied  sorts,  in  most  varied 
situations,  and,  as  they  differ  greatly  in  their  rapidity  of  growth,  the 
resultant  symptoms  vary  widely  in  character  and  degree. 

Surgery  has  had  much  to  do  with  this  change  of  opinion,  for  the 
promise  of  operative  relief  in  what  is  otherwise  a  hopeless  condition  has 
led  to  more  precocious  and  more  exact  methods  of  diagnosis.  It  is  but 
a  repetition  of  our  experience  with  the  disorders  of  the  appendix,  of 
the  gall-bladder,  of  the  stomach  and  duodenum:  for  a  few  years  ago 
an  ulcer  of  the  duodenum  was  a  rare  malady,  with  certain  classical 
sjTQptoms,  for  which  we  do  not  now  sit  and  wait.^ 

Most  tumors,  first  or  last,  lead  to  the  classical  symptoms  of  headache 
and  choked  disk — the  chief  subjective  as  well  as  the  most  reliable 
objective  indication  of  intracranial  pressure.     Though  pressure  dis- 

1  Received  ior  publication  May  6,  1916. 

2  Seven  years  ago  (Boston  Med.  and  Surg.  Jour.,  1909,  clxi,  71-80)  the  ■nTiter  had 
occasion  to  examine  the  incidence  of  brain  tumor  cases  in  the  Johns  Hopkins  Hospital 
records  and  found  that  in  approximately  25,000  admissions  in  the' medical  wards  over 
a  period  of  twenty  years  there  had  been  about  100  cases  diagnosed  as  tumor  or  presump- 
tive tumor.  As  there  were  about  20  cases  in  each  successive  5000  admissions,  0.4  per 
cent,  may  be  taken  to  represent  the  average  incidence  of  tumor  in  a  general  medical 
cUnic  which  receives  neurological  cases.  In  the  surgical  ser\dce  during  the  same  period, 
due  to  the  growing  interest  taken  in  these  disorders,  the  percentage  had  risen  from  0.06 
per  cent,  in  the  first  5000  admissions  to  over  3  per  cent,  in  the  last  1000.  In  the  first 
5000  admissions  to  the  surgical  ser^dce  at  the  Brigham  Hospital  there  have  been,  includ- 
ing pituitary  tumors,  approximately  400  tumor  cases,  8  per  cent.,  or  one  in  everj^  twelve 
admissions,  and  something  over  100  cases  a  year.  This  shows  how  attention  paid  to  a 
special  subject  may  modify  the  character  of  a  clinic. 

(407) 


408     PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

comforts  may  sometimes  undergo  spontaneous  retrogression,  as  in  a 
child  with  a  distensible  skull  or  in  the  case  of  a  pituitary  tumor  which 
succeeds  in  distending  the  sella  turcica,  still  in  the  general  run  of  cases 
a  persistent  increase  in  intracranial  tension  if  unrelieved  by  surgical 
measures  leads  to  great  physical  suffering  and  ultimately  to  loss  of 
vision.  For  the  purposes  of  our  present  topic  we  may  turn  our  atten- 
tion for  a  moment  to  these  two  most  characteristic  evidences  of 
tension. 


Fig.  135.— Example  of  an  improperly  placed  and  improperly  executed  so-called 
"decompression"  for  presumed  cerebral  tumor  (actually  a  cerebellar  endothelioma 
with  secondary  hydrocephalus).  Note  curNilinear  incision  and  position  of  defect  too 
high  to  be  protected  by  muscle.  Insecure  closure  of  wound  led  to  a  cerebrospinal  fluid 
leak;  the  extreme  protrusion  to  contralateral  hemiplegia.     (Compare  Figs.  177-180.) 

The  swelling  of  the  nerve  head  commonly  called  a  choked  disk 
or  more  appropriately  a  papilledema  is  properly  regarded  today  as 
largely  a  mechanical  process  due  to  the  stasis  of  cerebrospinal  fluid 
under  tension  within  the  subarachnoid  space  of  the  optic  nerve  sheaths. 
The  fluid  finally  backs  up  in  the  optic  nerves  themselves,  entering, 
according  to  Schieck,^  at  the  points  where  the  vessels  penetrate  the 

'Die  Genese  der  Staungspapille,  Wiesbaden,  1910,  p.  91. 


PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSIOX     409 

nerves,  thus  producing  a  chronic  edema  which  ultimately  leads  to 
destructive  scar  formation.  The  cerebrospinal  fluid  element,  therefore, 
is  the  important  one  and  a  choked  disk  depends  more  upon  the  situation 
than  on  the  size  of  a  tumor.  Thus  a  slowly  growing  tumor  of  a  cerebral 
hemisphere  may  reach  large  dimensions  before  a  choked  disk  appears, 
whereas  a  small  gro-^-th  accompanied  by  a  '^"idespread  cerebral  edema 
or  one  which  is  in  the  hind  brain  and  interferes  with  the  cerebrospinal 
fluid  outflow  through  the  iter  may  lead  to  a  high  grade  of  the  process  as 


Fig.  136. — Showing  intranasal  ether  administration;  area  of  shaving 
epidermal  incision. 


primary 


an  early  symptom.  On  the  other  hand,  tumors  such  as  pituitary  tumors 
which  press  upon  the  optic  nerves  and  thus  prevent  fluid  being  forced 
down  the  optic  sheath  are  rarely  accompanied  by  a  choked  disk,  even 
though  they  ultimately  may  reach  such  a  size  as  to  cause  an  internal 
hydrocephalus  from  obstruction  of  the  foramina  of  Munro. 

Headaches,  too,  are  attributed  to  tensioQ  and  they  vary  considerably 
in  their  situation  and  intensity.  Occasionally  the  discomforts  are  of 
localizing  value,  as  is  true  of  suboccipital  headaches  accompanying 
cerebellar  tumors  and  the  bitemporal  headaches  characterizing  pitui- 
tary growths,  but  as  a  rule  they  are  described  as  a  general  unlocalized 


410    PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

pressure  discomfort  which  may  be  so  intense  as  to  stupify  and  to  give  a 
sensation  as  though  the  head  would  burst.  It  is  not  entirely  clear  just 
what  produces  the  sensation  of  headache,  for  the  brain  is  insensitive. 
The  dura,  however,  is  a  sensitized  structure,  its  nerve  supply  being 
wholly  trigeminal  except  for  a  small  area  around  the  foramen  magnum 
which  is  innervated  by  the  vagus,  and  in  all  likelihood  the  discomforts 
may  be  ascribed  to  stretching  of  this  membrane,  or  its  expansions  into 
falx  or  tentorium.  Certain  observations  lend  support  to  this  view. 
Thus,  after  a  total  trigeminal  neurectomy  for  neuralgia  such  headaches 


Fig.  137. — Layer  of  wet  bichloride  gauze. 


as  may  follow  the  operation,  whether  from  the  anesthetic  ot  loss  of 
cerebrospinal  fluid,  are  usually  referred  by  the  patient  to  the  sound 
side  on  which  the  dura  retains  its  sensation.  Then  again,  certain  forms 
of  headache  associated  with  an  enlargement  of  the  pituitary  gland  are 
evidently  due  to  distention  of  the  dural  capsule  of  the  gland,  for  they 
are  apt  to  cease  when  the  growth  finally  breaks  through  the  capsule 
just  as  they  may  cease  abruptly  after  a  transsphenoidal  operation  in 
which  the  floor  of  the  sella  turcica  has  been  removed  and  the  dura 
incised  (sellar  decompression).     These  things  make  it  probable  that 


PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION    411 

distention  of  the  sensitized  dura  is  at  least  an  important  element,  if 
not  the  primary  element  in  those  forms  of  cephalalgia  which  are  asso- 
ciated with  a  local  or  general  increase  of  tension. 

Extirpation  of  a  lesion,  wherever  it  may  happen  to  be  and  par- 
ticularly if  it  be  a  new  growi:h,  is  the  ideal  sm-gical  procedure,  but  a 
valuable  alternative  and  the  only  alternative  in  the  case  of  an  intra- 
cranial tumor  which  cannot  be  definitely  localized,  or  if  localizable 
proves  inaccessible,  is  to  relieve  the  factors  of  tension  which  are  produc- 
ing these  SATiiptoms.    The  idea  of  a  purposeful  operation  which  has  as 


Fig.  138. — Primary  circular  toweling  pinned  in  scalp. 


its  objective  the  mere  relief  of  pressure  in  these  conditions  was  slow  in 
its  development.  This  may  doubtless  be  attributed  in  part  to  the  con- 
fusion which  long  existed  regarding  the  causative  factor  in  the  production 
of  a  choked  disk  for,  as  the  long-used  term  "optic  neuritis"  signifies,  the 
process,  in  the  minds  of  many,  was  due  to  an  inflammation  or  to  some 
sort  of  neurotoxic  effect  on  the  optic  nerves  produced  by  the  growth. 
From  this  viewpoint,  an  operation  which  did  not  serve  to  remove  the 
tumor  could  hardly  have  been  expected  to  check  the  optic  neuritis. 
Some  ten  years  ago,  however,  the  early  view  that  the  process  was 


412     PURPOSE  AXD  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

largely  mechanical,  rather  than  toxic  or  inflammatory,  was  revived 
and  came  to  prevail;  and  not  the  least  important  argument  in  its 
favor  was  the  fact  that  exploratory  operations  which  had  failed  in  their 
object  of  tumor  removal  sometimes  served  unexpectedly  to  relieve 
headaches  and,  what  was  more,  to  preserve  \'ision. 

It  is  remarkable  that  this  was  not  appreciated  earlier,  for  neurologists 
and  surgeons  must  often  have  seen  examples  of  spontaneous  palliation 
of  s\Tnptoms,  such  as  may  follow  the  pressure  absorption,  by  a  sub- 
jacent tumor,  of  the  overlying  skull,  or  the  diastasis  of  the  sutures  in 


Fig.  139. — Secondary  toweling  pinned  in  tragus. 


pre-adolescent  indi^^duals,  •udth  consequent  relief  of  headaches.  How- 
ever, a  discouraging  opinion  regarding  the  futility  of  all  operations  for 
tumor,  except  those  involving  the  motor  cortex,  had  been  pronounced 
in  Germany  by  von  Bergmann  and  in  this  country  by  Agnew.  Cases, 
if  operated  upon  at  all,  were  apt  to  be  operated  upon  late  in  the  disease, 
when  a  choked  disk  was  so  far  advanced  that  blindness  might  ensue 
even  though  a  tumor  was  removed  and  tension  completely  relieved. 
Moreover,  the  methods  of  entering  the  cranial  chamber,  and  particularly 
of  closing  the  wound  afterward,  were  so  imperfect  that  when  great 


PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION    413 

tension  was  encountered,  a  fungus  cerebri  and  its  distressing  conse- 
quences often  followed.  But  despite  all  discouragements,  some  sur- 
geons, notably  Sir  Victor  Horsley,  persisted  in  their  efforts  to  relieve 
these  cases  and  urged  that  more  precocious  explorations  be  made  on  the 
basis  that  they  might  serve  to  pa'liate  the  major  pressure  symptoms 
even  though  no  tumor  be  found  and  removed.  This  possibility  that  an 
exploratory  operation  which  fails  to  disclose  an  expected  tumor  may 
nevertheless  afford  unexpected  relief  was  first  clearly  expressed,  so  far 
as  I  am  aware,  by  Robert  F.  Weir^  in  1888  on  the  basis  of  a  single 


Fig.  140. — White  operative  sheet  with  indented  opening  and  tapes. 


experience.  Similar  experiences  were  soon  recorded  by  others  (Horsley 
in  1889,  Sahli  in  1891,  Jaboulay  in  1893,  Annandale,  Keen,  Sanger  and 
Bramwell  in  1894,  etc.),  as  Spiller  and  Frazier^  in  an  article  on  the 
subject  have  pointed  out. 

A  cranial  exploration  which  is  unsuccessful  in  its  purpose  of  tumor 
exposure  and  removal  can,  however,  hardly  be  placed  in  the  same 
category  as  the  present  day  purposeful  decompressive  craniectomy,  and 

1  Weir  and  Sequin  cit.,  cf.  H.  Gushing:    Jour.  Am.  Med.  Assn.,  1909,  Hi,  184-192. 

2  Jour.  Am.  Med.  Assn.,  1906,  xlvii,  679,  744,  849,  923. 


414     PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

though  these  operations  doubtless  grew  out  of  them,  it  was  many  years 
before  the  idea  got  a  footing  among  the_^profession  in  generah  Among 
the  earhest  to  clearly  adv^ocate  a  craniectomy  for  the  relief  of  pressure 
symptoms  was  Victor  Horsley/  first  at  the  Berlin  Congress  of  1895 
and  three  years  later  at  a  meeting  of  the  British  Medical  Association. 
At  that  time  he  favored  a  large  bone  defect  over  the  accessible  portion 
of  the  hemisphere  thought  to  be  involved  but  without  opening  the  dura. 
The  term  trepanation  decompressive  was  adopted  in  France  by  Jabouley^ 


Final  gray  covering. 


in  1896  and  in  the  same  year  employed  by  Broca  and  Maubrac^  in  the 
sense  in  which  we  now  use  it.  At  the  outset  it  was  supposed  that  an 
opening  made  anj'where  in  the  skull  would  serve  the  purpose,  but  great 
hesistancy  was  expressed  by  all  in  regard  to  the  propriety  of  opening 
the  dura,  as  a  substitute  for  which  Sanger  advocated  a  ventricular,  and 
Broca  and  Maubrac  a  lumbar  puncture. 

1  British  Med.  Jour.,  1890,  ii,  128G;  Ibid.,  1893,  ii,  1365. 
-Lyon  mod.,  1896,  Ixxxiii,  73. 
3  Arch.  gen.  do  niSd.,  1893,  i,  129. 


PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION     415 


Most  of  the  early  operations  for  tumor  have  been  undertaken  in  cases 
in  which  the  paracentral  (sensorimotor)  convolutions  were  presumably 
involved,  for  the  very  evident  reasons  that  here  a  localizing  diagnosis 
is  comparatively  simple  and  the  area  is  the  most  favorable  for  surgical 
Unhappily,  however,  if  a  tumor  were  not  found  and  tension 


access. 


proved  to  be  great,  a  formidable  protrusion  often  occurred  with  marked 


Fig.  142. — Fingers  as  tourniquet  preliminary  to  incision. 


accentuation  of  the  preexisting  local  sjTuptoms,  even  though  the  sub- 
jective headache  and  the  choked  disk  might  have  been  relieved.  Then 
if  the  exploration  happened  to  be  made  over  the  leading  hemisphere 
and  aphasia  was  superadded  to  the  hemiplegia,  the  patient's  helpless- 
ness was  so  accentuated  as  to  entirely  outweight  the  subjective  relief. 
Though  Byron  Bramwell  and  Bruns  had  somewhat  hesitatingly 
advocated  purposeful  trephining  for  palliative  purposes,  Sanger  was 


416     PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

one  of  the  first  neurologists  to  speak  emphatically  on  the  subject^  and 
in  1902^  he  advocated  the  establishment  of  a  cranial  and  dural  defect 
over  a  relatively  silent  area  of  the  brain,  his  favored  site  being  the  pos- 
terior portion  of  the  right  hemisphere.  This  procedure,  however,  may 
lead  to  an  unsightly  and  unnecessarily  large  protrusion,  particularly 
when,  as  is  often  the  case,  distention  of  the  ventricles  is  a  compli- 
cating factor  (Fig.  135),  and  ten  years  ago,  for  the  first  time  I  believe, 


Fig.  143. — Clamps  placed  on  galea,  liberating  fiuger.s  of  one  assistant. 

a  description  was  given  of  operative  methods  which  had  for  then* 
object  the  purposeful  herniation  of  a  silent  area  of  the  brain  under  a 
muscular  protection.* 

1  He  then  wrote:  "Palliative  trepanation  in  case  of  cerebral  tumor  is  an  operation 
which  even  if  not  absolutely  free  from  danger  is  of  extraordinary  blessedness,  and,  in 
the  hands  of  a  practiced  surgeon,  one  that  I  would  like  to  recommend  in  every  case,  in 
consideration  of  the  impotency  of  internal  medicine,  in  view  of  the  distressing  suffering, 
and,  above  all,  of  the  menacing  blindness." 

2  Sanger:     Deutsch.  Gesell.  f.  Chir.,  1902. 

'Gushing,  H.:     Surg.,  Gynec.  and  Obst.,  1905,  i,  295-314. 


PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION   417 

Considering  the  fact  that  these  matters  are  all  of  such  comparatively 
recent  date,  it  is  no  occasion  for  surprise  that  those  who  have  not  fol- 
lowed them  closely  still  have  somewhat  hazy  ideas  concerning  the 
principles  involved  in  a  cerebral  decompression,  which,  to  recapitulate, 
arose  from  the  finding  (1)  that  a  craniectomy  with  a  sufficient  opening 
of  the  dura  may  relieve  headache  and  choked  disk  even  without  tumor 
removal,  (2)  that  a  craniotomy  over  an  important  cortical  area  may 
lefaid  to  functional  injury  of  that  area  in  consequence  of  the  ensuing 
protrusion,  (3)  that,  therefore,  the  defect  in  the  bone  and  dura  should 


Fig.  144. — Showing  proper  placement  of  clamps.     (Natural  size.) 

be  madfe  over  a  relatively  silent  area  of  the  brain,  (4)  that  this  area  if 
protected  only  by  scalp  often  leads  to  a  most  unsightly  and  unneces- 
sarily large  protrusion  and  hence,  (5)  that  if  possible  it  is  wise  to 
decompress  for  supratentorial  lesions  over  an  area  which  can  be  pro- 
tected by  the  careful  closure  of  moderately  resistant  tissues,  such  as 
are  afforded  by  the  temporal  muscle  and  its  fascia. 

In  1905  when  the  palliative  operation  which  embodied  these  prin- 
ciples was  first  described,  experiences  with  it  had  been  few  and  its 
actual  value  was  somewhat  problematical.   The  operation  was  unwisely 

VOL.  I — 27 


418     PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

called  an  "  iiitermusculotemporal"  })rocediire  from  the  desire  to 
emphasize  that  the  temporal  muscle  and  fascia  were  split  as  in  the  inter- 
muscular laparotomies  which  avoid  the  transsection  of  muscle  fibers. 
For  this  cumbersome  name  the  better  term  "subtemporal"  craniec- 
tomy or  decom])ression  was  later  substituted. 


Fig.  145. — Incision  through  fascia. 


The  operation,  furthermore,  must  have  been  badly  described,  for 
many  seem  to  have  gained  the  impression,  possibly  from  the  illus- 
trations of  an  incomplete  stage  of  the  procedure,  that  the  dura  was  not 
to  be  opened;  unfortunately,  too,  a  curvilinear  skin  incision  was  advo- 
cated and  pictured,  the  object  being  to  still  further  accentuate  the 
"  gridiron"  approach  through  the  cranial  coverings.  It  was  soon  found 
that  this  curved  incision  interfered  with  a  possible  subsequent  osteo- 
plastic exploration  on  the  same  side  and  was  objectionable  also  since 
through  it  the  base  of  the  temporal  fossa  was  difficult  of  access.  More- 
over it  was  four.d  to  be  unnecessary,  for  with  the  separate  closure  of  the 


PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION   419 

galea  by  buried  sutures,  the  scalp  wound  was  found  to  be  sufSciently 
secure  even  though  it  directly  overlay  the  incisions  through  muscle 
and  fascia. 


Fig.  146. — Elevation  of  temporal  muscle  after  incision. 


Fig.  147. — Form  of  elevator  tVir  temporal  muscle.      (Natural  size.) 


420    PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

With  the  gradual  adaptation  of  the  operation  to  cases  of  basal 
fracture^  in  which  a  rubber  tissue  drain  for  cerebrospinal  fluid  is  advan- 
tageously left  emerging  from  the  lower  angle  of  the  incision,  a  linear 
incision  through  all  the  layers  came  to  be  the  approved  method.  This 
modification  was  described  in  1908  but  has  apparently  not  been  gener- 
ally followed,  judging  from  the  examples  of  so-called  subtemporal 
decompressions  which  frequently  come  under  observation.  Many  of 
them  have  curvilinear  scalp  incisions  with  a  cranial  defect  which  is 


Fig.  148. — Primary  opening  with  burr. 

either  too  small  to  be  effective  even  if  the  dura  has  been  opened,  which 
it  often  is  not,  or  so  high  that  contralateral  paralyses  may  be  expected; 
and  in  not  a  few  a  bone  flap  has  been  turned  back  and  replaced.  From 
these  ineffective  procedures  it  is  clear  why  objections  to  the  operation 
have  arisen  on  the  score  of  too  small  an  opening  or  of  distressing  con- 
sequences when  the  opening  is  sufficiently  large  {cf.  Fig.  135). 

1  Gushing,  H.:     Ann.  Surg.,  1908,  pp.  641-644. 


PURPOSE  AXD  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSIOX    -121 

Though  the  simplest  and  safest  of  all  the  operations  vrhich  are  called 
for  in  the  various  surgical  problems  presented  by  intracranial  tiunors, 
there  nevertheless  are  technical  difficulties  connected  with  it  which 
demand  practice  and  properly  constructed  instrtunents,  but  this  is 
true  enough  of  all  craniocerebral  procediu-es.  In  the  cotu-se  of  some 
three  or  four  himdred  decompressions  we  have  learned  how  to  aA'oid 
operative  comphcations  and  accidents,  and  it  is  the  piupose  of  this 
article  to  describe  m  detail  the  various  steps  of  the  procedure.    Some  of 


Fig.  119. — F'arther  enLargement  vrirh  Montenovesi  forceps. 

the  technical  improvements  adopted  since  the  early  description  of  the 
operation  fourteen  years  ago  lie  in  the  use  of  gray  operating  sheets,  in 
the  control  of  hemorrhage  from  the  scalp  by  digital  compression,  in  the 
use  of  silver  cUps  for  the  meningeal  branches  divided  with  the  diu-a,  of 
proper  retractors  to  elevate  the  muscle,  of  the  spoon  spatula  to  control 
marked  cerebral  protrusion  during  closure,  of  ventricular  puncture  to 
lower  tension  and  to  aid  in  diagnosis,  and  finally  in  the  method  of 


422     PURPOSE  AXD  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

closure  in  three  or  four  layers  of  buried  sutures  includine  the  fascia 
and  galea. 

The  accompanying  photographs  were  taken  during  the  course  of  the 
usual  decompression  for  an  unlocalized  tumor  and  the  comparative 
freedom  from  blood  staining  can  be  taken  as  an  e\'idence  of  the  effec- 
tive hemostasis,  though  admittedly  all  of  these  operations  are  not 


Fig.   150. — Introduction  of  flat  rongeurs  well  under  muscle  for  further  enlargement. 


equally  dry.    For  convenience  of  description  we  may  di\'ide  the  pro- 
cedure into  the  following  steps: 

.-1.  Anesthesia  and  preparation  of  the  field  (Figs.  136  to  141). 

B.  The  incision  to  completion  of  the  subtemporal  bone  defect  (Figs. 
142  to  152). 

C.  The  dural  opening  and  cerebral  exploration,  this  being  the  essen- 
tial p^rt  of  the  operation  (Figs.  153  to  100). 

D.  The  closure  and  dressings  (Figs.  IGl  to  173.) 


ANESTHESIA  AND  FIELD  PREPARATION 


423 


A.  Anesthesia  and  Field  Preparation.— The  importance  of  excep- 
tionally skilful  anesthesia  cannot  be  emphasized  too  greatly.  Patients 
suffering  from  the  effects  of  intracranial  tension  are  notoriously  bad 


Fig.  151. — Flat-nosed  rongeur  for  insertion  under  muscle  edges.     (Natural  size.) 


Fig.  152. — Same  as  preceding,  rongeurs  reaching  well  toward  base  of   skull. 


424     PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

subjects  for  narcosis  and  different  operators  favor  different  methods 
and  different  drugs.  Some  advocate  local  anesthesia,  which  has  its 
many  objections.  The  inhalation  narcotics  are  apt  to  increase  tension 
owing  to  the  increased  secretion  of  cerebrospinal  fluid  which  they 
apparently  induce,  and  this  is  accentuated  if  the  patient  is  permitted 
to  become  at  all  cyanosed,  as  is  more  or  less  inevitable  with  nitrous 
oxide.    Chloroform  or  mixtures  which  contain  chloroform  have  their 


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Fig.  153. — Primary  incision  in  dura. 

especial  dangers  and,  taken  all  in  all,  straight  ether  anesthesia  may 
be  regarded  as  the  safest  and  best  method. '^  This  was  formerly  given 
by  the  drop  method  throughout,  but  during  the  last  four  years,  when 

*  The  comparative  freedom  from  ether  accidents  and  operative  difficulties  owing  to 
ether  during  many  cranial  operations  in  a  long  series  of  cases  in  the  past  ten  years  is 
due  entirely  to  the  exceptional  skill  of  Dr.  S.  G.  Davis,  of  Baltimore,  and  Dr.  Walter 
Boothby,  of  Boston,  who  have  anesthetized  practically  all  of  them.  (C/.  This  paper 
was  written  in  1914.) 


ANESTHESIA  AND  FIELD  PREPARATION 


425 


secondary  narcosis  is  once  induced  by  the  drop  method  and  mask  it  is 
supplanted  by  ether  vapor  under  a  measured  tension  given  by  the 
Connell  apparatus  through  a  tube  introduced  through  the  nares  into 
the  pharynx.  By  this  method  the  anesthetist  is  removed  from  the 
operative  field  and  the  induced  sleep  is  usually  so  quiet  and  regular 
that  the  distracting  anxiety  concerning  the  anesthetic  is  eliminated. 

The  operative  field  is  shaved  the  morning  of  operation.  That  shown 
in  Fig.  136  is  larger  than  necessary.  All  antecedent  preparations  of 
the  scalp  are  to  be  avoided,  for  they  accomplish  little  more  than  to  give 


Fig.  154. — Same  as  preceding  (natural  size)  to  show  dural  hook. 


the  patient  a  restless  night.  These  operations  are  palliative,  it  is  to  be 
remembered,  and  many  of  the  patients  may  soon  return  to  their 
occupations.  Particularly  in  women  it  is  desirable  to  avoid  shaving 
more  than  the  necessary  small  strip  bordering  the  line  of  proposed 
incision.  The  hair  should  be  brushed  away  and  tightly  braided  in  a 
single  braid  centering  in  the  opposite  parietal  region.  Cotton  is  placed 
in  the  auditory  canal  and  the  scalp  is  cleaned  merely  by  sponging  with 


420    PURPOSE  AXD  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

some  green  soap  followed  !)>'  alcohol  and  liichloride.     Personally,  1 
detest  iodin  preparations.' 

In  all  cranial  operations  the  towels  sliould  be  securely  disposed 
closely  about  the  wound  and,  to  prevent  slipping  during  the  course  of 
a  possible  prolonged  operation,  they  should  be  pinned  into  the  scalp, 
leaving  nothing  exposed  but  the  actual  line  of  incision.  This  means, 
therefore,  the  complete  covering  of  all  landmarks,  so  that  it  is  custom- 


FiG.  155. — -Further  incision  on  grooved  director;  note  clips  on  vessels.      (Natural  size.) 

ary  before  placing  the  towels  to  make  an  epidermal  incision  (Fig.  136). 
In  the  operation  under  discussion  this  scratch,  about  10  cm.  long, 
should  run,  with  a  slight  obliquity  backward,  from  the  upper  edge  of  the 
zygoma  slightly  in  front  of  the  ear  to  a  point  just  below  the  parietal 
eminence. 


1  In  the  only  infection  in  my  entire  series  of  decompressions,  the  patient's  head  had 
been  completelj'  shaved  and  elaborately  scrubbed  and  disinfected.  I  was  persuaded 
to  operate  in  unfamiliar  surroundings  and  a  rubter  dam  tourniquet  was  employed, 
and  there  were  other  technical  features  of  the  procedure  which  were  obviously  bad. 
Unquestionably  all  complex  craniocerebral  operations  should  be  home  operations  in 
the  company  of  assistants  fully  trained  to  an  established  technic. 


ANESTHESIA  AND  FIELD  PREPARATION 


427 


Over  the  entire  head  a  layer  of  wet  bichloride  gauze  is  then  thrown 
(Fig.  137)  and  with  the  head  lifted  by  the  orderly's  hand  under  the  neck, 
two  layers  of  damp  towels  are  placed  under  the  head,  carrying  the 
gauze  with  them.  The  upper  folded  towel  is  then  wrapped  snugly 
about  the  head,  catching  at  occiput  and  orbit,  and  is  pinned  into  the 
scalp  at  the  point  of  crossing  at  the  upper  end  of  the  incision  (Fig.  138). 
The  next  towel  is  then  laid  along  the  posterior  edge  of  the  incision  and 


Fig.  156. — The  placing  of  a  silver  clip  on  the  bleeding  margin  of  the  incised  dura. 


when  pinned  into  the  skin  in  front  of  the  tragus  is  wrapped  around  the 
head  as  shown  (Fig.  139).  This  is  followed  by  a  large  operating  sheet 
which  is  thrown  over  the  anesthetist's  bracket,  the  instrument  stand 
and  all,  and  in  the  edge  of  which  is  a  circular  notch.  The  margin  of 
this  notch  is  caught  under  the  pins  and  the  tapes  at  its  corners  are  tied 
around  the  field  (Fig.  140) .  This  is  followed  by  the  final  grav  covering 
(Fig.  141).  ... 
It  sounds  like  an  Irishism  to  say  that  the  better  the  light  the  more 


428     PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

difficult  it  is  to  see  into  a  deep  hole.  But  it  is  true,  particularly  when  a 
wound  is  surrounded  by  the  white  operating  sheets  so  commonly  used 
which  serve  merely  to  contract  the  pupils  and  incommode  vision. 
Then,  too,  in  the  course  of  most  of  these  operations  a  head  light  is 
advantageously  employed  to  throw  a  concentrated  light  directly  on 
areas  in  the  depths  and  with  white  surroundings  there  are  annoying 
reflections.^ 


Fig.  157.— Lateral  incision  with  spoon  director. 

There  are  doubtless  other  and  equally  good  ways  of  placing  these 
coverings,  but  what  should  be  emphasized  is  that  they  must  be  anchored 
securely  in  position  in  view  of  the  small  linear  field  of  preparation. 

>  A  complete  gray  equipment  for  the  operating  room,  including  gowns  and  toweling, 
has  been  employed  since  the  opening  of  the  Brigham  Hospital  four  years  ago  with 
increasing  satisfaction.  Others  have  long  appreciatad  the  value  of  color  protection. 
Carrel  has  long  used  black,  but  this  is  too  funereal  for  a  hospital  operating  room,  and 
the  color  soon  rusts.  Sherman  speaks  highly  of  the  green  equipment  which  he  has 
installed  in  San  Francisco.  Gray  we  find  particularly  restful  to  the  eyes,  but  almost 
anything  is  better  than  white,  which  has  been  so  long  employed. 


EXTRACRANIAL  INCISION  AND  THE  BONE  DEFECT        429 

B.  The  Extracranial  Incision  and  the  Bone  Defect. — There  are  many- 
ways  of  controlling  bleeding  from  the  scalp.  In  this  particular  oper- 
ation the  incision  is  made  in  the  vascular  temporal  area  and  the 
vessels  will  be  divided  at  many  points.  Our  favored  method  in  all 
cases  is  by  finger  compression  made  by  the  two  assistants  over  gauze 
sponges  laid  along  the  margin  of  the  epidermal  scratch  (Fig.  142)  and 
these  sponges  remain  undisturbed  until  the  closure. 


Fig.  ISS.^Lateral  incision  completed,  brain  protrudinff  tilightly. 

After  the  incision  has  been  carried  through  the  galea  aponeurotica 
down  to  the  temporal  fascia,  the  operator  places  a  series  of  pointed 
Halsted  clamps  on  the  galea  to  the  right,  freeing  the  assistant  on  that 
side  (Fig.  143).  When  the  clamps  fall  back  they  fold  the  loose  galea 
over  the  scalp  and  completely  check  bleeding  without  the  necessity  of 
including  and  crushing  any  of  the  fat  in  their  jaws  (Fig.  144).  The 
hands  of  the  assistant  on  the  left  are  then  freed  in  like  manner. 

The  temporal  fascia  is  then  divided  (Fig.  145)  and  after  the  incision 
is  carried  through  the  temporal  muscle  practically  in  line  with  its 


430     PURPOSE  AXD  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

fibers,  the  muscle  and  epicranium  are  scra])ed  from  the  bone  by  proper 
periosteal  elevators  (Fig.  14G)  while  the  nuiscle  edges  are  held  up  by 
retractors  of  a  particular  form  (Fig.  147).  If  the  patient's  mouth  is 
closed,  the  muscle  edges  may  be  sufficiently  elevated  to  permit  the 
insertion  of  the  rongeurs  under  them  during  the  subsequent  stages 
without  putting  such  strain  on  the  edges  as  to  strip  them  from  the 
skull  at  their  upper  margins  of  attachment  along  the  temporal  ridge. 
The  muscle  should  be  carefully  freed  from  its  cranial  attachment  well 
down  in  the  temporal  fossa,  and  from  there"  up  to  its  upper  margin 
along  the  temporal  ridge. 


Fig.  1.59. — Same  as  Fig.  158  (uatural  size),  showing  the  usual  cortical  appearance  with 
Syhdan  veins  at  the  near  angle  of  the  wound. 


In  the  center  of  the  denuded  area  of  bone  a  primary  opening  (Fig. 
148)  is  made  with  a  burr  and  this  is  enlarged  downward  with  Monteno- 
vesi  forceps  (Fig.  149)  until  a  sufficient  opening  is  secured  for  the  ron- 
geurs. Successful  rongeuring  is  one  of  the  difficult  features  of  the 
operation  (Fig.  150)  and  requires  very  flat-nosed  instruments  (cf.  Fig. 
151),  else  they  cannot  be  inserted  under  the  muscle  without  stripping 


EXTRACRANIAL  INCISION  AND  THE  BONE  DEFECT        431 

it  from  its  attachments  to  the  skull.  If  the  patient  has  a  very  vascular 
diploe,  the  difficulties  of  rongeuring  may  be  considerable  and  constant 
waxing  of  the  margin  is  necessary.  In  the  depth  this  cannot  be  done 
with  the  fingers  without  crowding  the  wax  under  the  edge  of  bone,  but 
it  can  be  accurately  placed  and  rubbed  into  the  diploe  by  small  flat 
pledgets  of  cotton  wrung  out  from  warm  salt  solution  and  held  in  a  pair 
of  forceps.  It  may  be  said  that,  to  the  complete  avoidance  of  gauze,  all 
sponging  of  these  wounds  and  particularly  of  the  brain  itself  is  restricted 
to  these  damp  cotton  pledgets,  which  may  be  seen  lying  about  in  some 
of  the  photographs  {e.  g.,  Figs.  150  and  152). 


Fig.   160. — Insertion  ul   curved  aspirating  needle  into  ventricle  of  temporal  lobe. 

The  subtemporal  bone  is  gradually  rongeured  away  until  as  large  an 
area  as  possible  is  removed,  averaj^ing  in  adults  about  6  by  8  cm.  Care 
should  be  taken  to  bit^  the  fragments  outward  lest  the  brain  be  con- 
tused by  the  jump  of  the  forceps  and  especial  precautions  must  be  taken 
in  approaching  the  pterion,  where  the  meningeal  may  be  injured  and  the 
field  flooded  if  the  vessel  is  not  controlled  immediateh'.     The  thin 


432     PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

plate  of  bone  from  the  lower  field  well  down  in  the  temporal  fossa  is 
most  easily  broken  out  (Fig.  152)  and  should  be  thoroughly  removed. 

Before  venturing  to  open  the  dura  the  field  should  be  quite  dry,  for 
with  a  denuded  and  protruding  brain  it  is  most  difficult  to  control  any 
oozing  left  during  this  preparatory  stage. 

C.  The  Dural  Opening  and  Cerebral  Exploration. — It  is  in  this,  the 
vital  stage  of  the  operation,  that  experience  is  put  to  the  test.  As  the 
dura  is  apt  to  be  tense  and  the  brain  "dry,"  great  care  must  be  exer- 
cised in  making  the  primary  opening  in  the  dura  (Fig.  153)  and  after 
the  first  nick  in  the  outer  layer  of  the  membrane,  a  fine  curved  hook 
may  be  inserted  under  it  and  the  membrane  drawn  upon  to  facilitate 
a  safe  entry  (Fig.  154).  A  grooved  director  is  then  inserted  and  the 
incision  prolonged  downward,  "silver  clips"  being  immediately  placed 
(Figs.  155  and  156)  on  the  branches  of  the  meningeal  before  or  after 
their  division,  as  is  most  convenient. 


Fig.  161. — Diagram  of  the  indi\ddual  layers  of  closure. 

These  clips,  useful  for  all  operative  work,  were  designed  for  this 
special  purpose  and  particularly  when  the  radial  incisions  are  being 
carried  well  under  the  muscle  to  the  margins  of  the  bone  defect  where 
meningeal  branches  inaccessible  to  the  ligature  may  be  encountered, 
the  de\4ce  is  an  invaluable  one.  As  the  lateral  incisions  are  cut  it  is 
well  to  protect  the  protruding  temporal  lobe  with  the  spoon  spatula 
lest  it  be  injured  (Fig.  157).  A  good  deal  of  skill  and  expedition  is 
required  at  this  period,  particidarly  if  the  tension  is  considerable  and 
if  contusions  and  subcortical  extravasations  are  to  be  avoided  as  they 
should  be  (Fig.  158).  The  field  of  cortex  as  finally  exposed  reaches,  as 
a  rule,  slightly  above  the  Sylvian  fissure,  which  is  easily  identified  by 
its  large  veins  (Fig.  159). 

One  must  not  forget  that  in  the  course  of  a  decompression,  though  it 
be  primarily  a  palliative  measure,  much  of  value  for  purposes  of  subse- 
quent localization  may  be  learned  from  the  appearance  of  the  exposed 


DURAL  OPEXIXG  AXD  CEREBRAL  EXPLORATION 


433 


cortex,  the  position  of  the  vessels,  the  conditions  disclosed  by  palpation, 
and  the  presence  or  absence  of  fluid  in  the  arachnoid  spaces  or  ventri- 
cles. For  example,  if  the  Syh-ian  fissure  is  pushed  upvvard  \vith  ob^■ious 
broadening  of  the  three  temporal  gy^'i,  one  may  be  fairly  confident  of 
an  imderlying  lesion  for,  be  it  remembered,  the  operation  is  chiefly 
performed  for  unlocalizable  tumors  and  as  the  defect  is  purposely 
made  over  the  temporal  convolutions  for  the  reason  that  this  is  a 
relatively  silent  area,  a  tumor  may  not  infrequently  be  found.    In  our 


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\ 

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■HBP*° ,--- 

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— -^ 

11^^ 

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M 

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ir\ 

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V 

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SPui 

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<-.„ 

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Fig.  162. — First  stage  of  clostire.     Brain  protected  by  spoon. 

series  of  possibly  200  decompressions  for  milocalized  tumors,  in  at 
least  fifteen  instances  we  have  unexpectedly  come  doT\m  upon  the  lesion. 
In  some  cases  it  has  proved  to  be  a  gliomatous  cyst  and  in  others  a 
solid  tumor  which  has  required  for  removal  a  subsequent  osteoplastic 
operation  in  order  to  expose  a  wider  area  of  the  hemisphere.  Four  of 
our  large  series  of  successfully  remoA'ed  endotheliomas  were  first 
accidentally  disclosed  in  the  Sylvian  angle  in  the  course  of  a  subtem- 
poral decompression. 

VOL.  I — 28 


434     PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

Careful  palpation  of  the  brain  may  enable  one  with  experience  to 
detect  the  peculiar  cortical  softness  produced  by  a  subjacent  gliomatous 
cyst  not  uncommon  in  the  temporal  lobe,  and  the  characteristic  elas- 
ticity of  the  lobe  associated  with  an  internal  h}'drocephalus  is  often 
recognizable.  A  wet  arachnoid  or  a  dilated  ventricle  indicates  that  a 
tumor,  at  least  one  of  any  considerable  size,  does  not  lie  in  the  exposed 
hemisphere.  For  this  reason  a  ventricular  puncture  into  the  tip  of  the 
temporal  horn  is  an  important  step  of  the  procedure.    With  experience 


Fig.  163. — Showing  placement  of  lowest  layer  of  sutures  at  inner  edge  of  muscle. 

(Natural  size.) 

and  a  good  visualization  of  the  ventricles,  the  hollow  and  slightly 
curved  exploratory  needle  may  be  introduced  into  the  temporal  horn 
through  the  second  or  third  g\Tus  (Fig.  160)  without  fail  if  the  ventricle 
is  dilated,  and  in  about  half  of  the  cases  if  it  is  not.  If  a  dilated  ven- 
tricle is  entered,  on  escape  of  the  fluid  the  protrusion  immediately 
collapses  and  all  subsequent  difficulties  of  closure  are  avoided.  We 
have  come  to  place  so  much  importance  on  this  step  that  when  excep- 
tional tension  is  encountered  and  there  is  fear  of  contusion  of  the  lobe 
from  excessive  protrusion,  the  ventricle  is  tapped  through  a  small 


CLOSURE 


435 


nick  in  the  dura  over  one  of  the  lower  convolutions  before  the  mem- 
brane is  incised. 

It  may  be  emphasized  again  that  all  possible  cortical  contusions  and 
extravasations  should  be  scrupulously  avoided,  for  they  merely  add  to 
preexisting  tension  and  if  this  is  considerable  there  may  be   great 


Fig.  164. — Showing  the  partial  closure  of  the  successive  layers  with  the  first  four  galea 
sutures  tied  to  relieve  tension  on  the  fascia. 


difficulty  in  making  a  secure  closure.  Moreover,  as  the  herniation 
progressively  increases,  unless  relieved  by  the  successful  withdrawal 
of  fluid  from  the  ventricle  or  a  chance  cyst,  no  time  is  to  be  wasted  after 
the  dura  is  once  fully  opened. 

D.  Closure. — This  should  be  in  layers.    Fine  silk  sutures  passed 
on  French  needles  are  preferred  since  any  heavier  material  is  likely  to 


436     PURPOSE  A^D  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

tear  through  and  spHt  the  deUcate  fascial  edge.  The  sutures  are  cut 
almost  at  the  knot  so  that  there  is  no  reaction  even  though  some  thirty 
knots  may  be  closely  superimposed  in  the  four  or  five  buried  layers  of 
the  incision  (rf.  Fig.  161). 

If  there  is  considerable  protrusion  of  the  denuded  lobe  this  should 
be  protected  by  the  spoon  (Fig.  1()2)  while  the  first  layer  of  sutures  at 
the  lower  border  of  the  incised  nniscle  are  being  placed  (Fig.  1G3).    The 


Fig.   165. — Further  advance  of  closure,  the  scalp  approximated  by  assistant's  fingers, 

while  tying  galea  sutures. 

spoon  is  withdraAvn  as  each  successive  suture, is  tied.  The  second 
layer  of  sutures  is  then  placed  in  the  outer  edge  of  the  incised  muscle 
and  not  infrequently  the  edges  of  the  inelastic  fascia,  which  have  been 
considerably  stretched  apart,  may  be  coaxed  together  by  two  or  three 
sutures  placed  as  an  extra  layer  in  the  loose  subfascial  connective  tissue. 
The  approximation  of  the  fascial  edges  is  the  most  difficult  for  the 
reasons  given,  and  in  most  cases  it  is  wise,  in  order  to  diminish  the 
tension  on  the  fascia,  to  place  and  tie  one  or  two  of  the  lower  galea 


CLOSURE  437 

sutures.  Thus  the  closure  is  partly  completed  in  steps  in  its  several 
layers  (Fig.  164).  The  deeper  layers  are  then  closed  through  their 
whole  length  and  the  remaining  galea  sutures  placed  and  tied  as  the 
clamps  are  removed  (Fig.  165).    As  the  suture  material  is  very  delicate, 


Fig.  166. — Detail  of  Fig.  165.     Final  closure  of  galea.     (Natural  size.) 

the  edges  of  the  scalp  should  be  approximated  by  pressure  of  the 
assistants'  fingers  (Fig.  166)  to  relieve  strain  on  the  sutures  while  tying. 
These  galea  sutures  are  then  drawn  taut  so  as  to  expose  the  knots  close 
to  which  they  are  cut  (Figs.  167  and  168). 


438     PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

There  is  no  better  way  of  closing  the  scalp  incision  than  by  the  place- 
ment of  a  row  of  straight  cambric  needles  which  heap  up  and  splint  the 
tissue  so  that  when  the  sutures  are  tied  at  the  side  an  absolutely 
accurate  edge-to-edge  approximation  of  epithelium  can  be  secured  with 
flat  wound  surfaces  so  brought  together  as  to  prevent  any  oozing. 
(Figs.  169  and  170).  Thus,  aside  from  the  silver  clips  on  the  dura,  no 
ligature  of  vessels  is  required  in  the  whole  operation.  These  details 
may  seem  extravagant,  but  if  they  are  not  followed  an  occasional  break- 
down or  leakage  of  fluid  will  inevitably  occur. 


Fig.  167. — -Cutting  of  galea  sutures  at  the  knot. 

The  original  sheets  and  towels  are  unpinned  and  unwrapped  (Fig. 
171),  exposing  the  wound  (Fig.  172),  which  is  dressed  preferably  with 
silver  foil.  In  applying  the  bandage,  care  should  be  taken  to  protect  the 
ear  from  pressure  lest  it  give  discomfort;  a  starched  roll  is  applied  over 
all  (Fig.  173).^  The  dressing  should  be  removed  and  the  scalp  sutures 
cut  after  forty-eight  hours,  at  which  time  a  collodion  gauze  dressing 

'  To  one  unaccustomed  to  operating  over  the  patient's  head  from  the  end  of  the 
table,  these  photographs  may  appear  to  be  upside  down,  and  the  head  to  be  hanging 
instead  of  slightly  elevated.  The  camera  was  placed  high  and  about  in  the  line  of  the 
operator's  vision. 


CLOSURE 


439 


may  be  applied,  and  at  the  end  of  a  week  the  wound  may  be  left  without 
a  support  (Fig.  1 74) .  The  incision  should  be  practically  invisible  and 
with  the  hair  trimmed  there  is  little  evidence  of  an  operation  having 
been  performed  except  for  the  slight  bulging  which  in  the  average  case 
is  not  obtrusive  (Fig.  175). 


t7\ 


Fig.  168. — Detail  of  preceding.     (Natural  size.) 

It  might  be  supposed  that  this  form  of  closure  is  oversecure  and  that 
by  preventing  a  herniation  it  might  combat  the  very  ends  for  which 
the  operation  was  undertaken.  As  a  matter  of  fact,  if  the  brain  is 
tense  the  herniation  gradually  stretches  the  tissue  so  that  the  pro- 
trusion slowly  enlarges,  but  there  is  no  excessive  protrusion  and  in  the 
entire  series  of  cases,  there  has  been  no  fungus  cerebri  or  cerebrospinal 
fluid  leak.  The  area  of  denudation  is  confined  practically  to  the  tem- 
poral lobe  (Fig.  176)  and  no  paralyses  of  any  kind  ensue  even  if  there 


440    PURPOSE  AS'D  STEPS  OF  A  SUBTEMPORAL  DECOM  PRESS  .ON 

is  considerable  protrusion  (//.  Figs.  177  to  180)  My  former  fears  that 
'the  auditory  centers  might  be  affected  under  these  circumstances  were 
without  foundation.  A  fairly  typical  bone  defect  is  shown  in  the  .r-ray 
(Fig.  181),  though  the  lateral  exposure  fails  to  indicate  the  depth  to 
which  the  defect  is  carried  at  the  lower  ])art  of  the  temporal  fossa. 


uiH'ifirial  needles  in  place  and  partly  tied. 


To  gain  some  idea  of  the  conditions  for  which  a  subtemporal  decom- 
pression may  be  performed,  the  following  tabulation  of  the  last  100 
consecutive  cases  in  the  writer's  series  has  been  made. 

1.  For  unlocalized  tumor  presumably  above  tentorium 37 

2.  For  localizable  but  inaccessible  tumor 23 

3.  Provisional  decompression  before  attempted  tumor  removal      ...  6 

4.  Decompression  for  multiple  cerebral  metastases 4 

5.  For  traumatic  craniocerebral  lesions  associated  with  Iracture  of  base  16 

6.  For  cerebral  abscess  simulating  tumor 2 

7.  For  chronic  serous  arachnoiditis  simulating  tumor 4 

8.  For  cerebral  syphilis  wath  pressure  symptoms 4 

9.  For  blastomycotic  meningitis  simulating  tumor 2 

10.  For  thrombotic  arteriosclerosis  simulating  tumor 1 

11.  For  otitic  meningitis 1 


100 


Fig.  170. — Detail  of  method  of  securing  fine  edge-to-edge  approximatioD. 


Fig.  171. — After  removal  of  pins  and  outer  gray  sheet. 


442    PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 


Fig.  172. — Exposure  of  sutured  wound,  before  silver  dressing 


Fig.  173. — Final  starch  dressing. 


Fig.   174. — After  six  days,  showing  moderate  bulging.     Patient  replaced  on  table 
and  photographed  in  position  of  other  figures. 


Fig.    175. — Eighth  day,  showing  moderate  bulging.     Patient  holding  up  hair 
which  otherwise  would  completely  cover  shaved  area. 


4U    PURPOSE  AXD  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSIOS 

There  were  6  deaths  in  the  series  which  might  be  attributed  to 
the  operation,  none  of  them,  however,  in  the  series  of  70  true  tumors  of 
the  first  four  groups,  all  of  which  were  benefited  in  varying  degrees. 
Death  occurred  soon  after  the  operation  in  three  of  the  acute  fracture 
cases  and  the  patient  with  extensive  arteriosclerosis  never  recovered 
from  the  anesthetic.    The  torula  meningitis  cases  likewise  were  vmre- 


FiG.  176. — Diagram  to  show  area  of  subcortical  denudation  in  subtemporal 
decompression. 


lieved  though  they  survived  for  several  wrecks.  The  otitic  case  also 
succumbed.  The  growth  has  subsequently  become  localizable  and  since 
been  operated  upon  in  7  of  the  37  cases  in  the  first  group  and  doubtless 
this  will  be  true  of  some  of  the  remaining  30  as  time  passes.  In  6  cases 
the  tumor  was  disclosed  in  the  temporal  lobe  at  the  time  of  the  original 
decompression  (three  endotheliomas;  three  gliomatous  cysts)  and  in  G 


CLOSURE 


445 


other  cases  a  dilated  ventricle  was  demonstrated,  a  matter  of  consider- 
able localizing  value  as  suggesting  a  posterior  lesion. 

This  list  of  course  does  not  include  decompressive  operations  for 
tumors  below  the  tentorium  nor  decompressive  measures  of  other  types 
which  possibly  should  not  be  dismissed  without  a  word  of  mention. 
A  subtemporal  decompression,  though  it  may  help  in  the  diagnosis  of 


Fig.  177 


Fig.  178 


Fig.  179 


Fig.  180 


Figs.  177,  178,  179,  180. — Photographs  taken  on  the  tenth  day  and  on  the  twenty-first 
day  after  a  decompression  disclosing  an  extensive  temporal  lobe  glioma,  with  temporary 
complete  relief  of  symptoms,  to  show  secure  healing  and  gradual  increase  of  herniation 
despite  the  secure  closure. 

an  obscure  lesion  by  disclosing  an  internal  hydrocephalus,  does  not 
greatly  relieve  the  tension  effects  of  a  cerebellar  tumor;  and  it  may  be 
added  that  no  decompressive  measure  is  of  great  avail  in  the  case  of 
pontine  gliomas,  for  these  lesions  as  a  rule  cause  serious  paralyses  long 
before  any  marked  pressure  symptoms  arise.  Unmistakable  subten- 
torial  tumors,  whether  intra-  or  extracerebellar,  should  be  approached 


440    PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

with  the  purpose  of  attack  at  the  first  session  and  if  they  are  not  dis- 
closed the  suboccipital  muscles  and  fasciae  should  be  closed  in  layers 
over  the  exposed  cerebellar  hemispheres,  thus  leaving  the  procedure 
as  a  decompressive  measure. 

Another  and  more  complicated  form  of  subtemporal  decompression 
which  often  proves  of  great  value,  is  one  combined  with  an  osteoplastic 
exploration.^  Thus  when  under  the  reasonable  expectation  that  a 
tumor  will  be  found  in  one  of  the  cerebral  hemispheres,  a  bone  flap 


Fig.  181.- 


-X-ray,  showing  average  defect,  made  in  a  subtemporal  decompression, 
clips  on  vessels  divided  in  dural  incision. 


Note 


has  been  reflected  and  the  tumor  not  disclosed,  it  is  the  common 
practice  to  strip  away  the  bone  and  close  the  scalp  alone  over  the  pro- 
truding brain.  If  there  is  so  great  tension  that  the  intact  flap  cannot  be 
replaced,  there  may  be  no  other  recourse,  or  if  an  inoperable  glioma  is 
exposed  it  is  probably  the  wisest  course  to  pursue.  However,  one 
always  desires  to  replace  a  flap  if  it  is  possible  or  reasonable  to  do  so,  if 
for  no  other  purpose  than  to  prevent  an  undue  protrusion  of  an  undesir- 


1  Cushinj!:,  H.:     Surj:.,  Gyncc.  and  Obst.,  190S,  ix,  1-5. 


CLOSURE 


447 


able  area  which  may  lead  to  contralateral  palsies  or  accentuate  those 
which  were  preexistent.  These  ill  effects  may  often  be  obviated  by 
rongeuring  away  the  area  of  bone  which  underlies  the  temporal  muscle, 
not  only  from  the  reflected  flap  but  also  well  dovm  into  the  middle 
cranial  fossa.  The  dura  is  then  closed  with  the  exception  of  the  portion 
corresponding  to  this  subtemporal  defect  and  the  flap  replaced,  leaving 
an  opening  in  the  skull  in  the  same  situation  as  that  which  would  be 
made  in  the  course  of  a  subtemporal  decompression  conducted  as  a 


Fig.  182. — To  illustrate  a  methcd  of  combining  a  subtemporal  decompression  after 
an  osteoplastic  exploration  which  has  failed  to  reveal  a  suspected  lesion. 

primary  measure  (Fig.  182).  Under  these  circumstances  in  the  course 
of  time,  the  osteoplastic  flap  may  lift  somewhat  and  add  to  the  room 
gained  by  the  subtemporal  protrusion. 

Another  decompressive  measure,  which  was  originated  by  von 
Bramann,!  is  the  so-called  Balke7istich  or  callosal  puncture  highly 
recommended  for  cases  with  a  secondary  internal  hydrocephalus  due  to 


1  Arch.  f.  klin.  Chir.,  1909,  xc,  GS9. 


448    PURPOSE  AND  STEPS  OF  A  SUBTEMPORAL  DECOMPRESSION 

posterior  lesions  which  obstruct  the  cerebrospinal  fluid.    This  measure, 
in  the  writer's  experience,  has  been  largely  disappointing. 

Thus  there  are  various  procedures  which  serve  the  purposes  of  decom- 
pression— namely,  to  furnish  relief  to  the  tension  phenomena  produced 
by  tumors  or  other  conditions.  In  the  long  run,  however,  the  sub- 
temporal operation  is  the  simplest,  safest  and,  for  the  average  case, 
most  satisfactory  of  all  palliative  surgical  measures  as  yet  suggested 
for  tumors  when  they  are  either  unlocalizable,  or  inaccessible,  or  when 
some  temporary  measure  of  relief  is  desirable  to  improve  the  condition 
of  a  patient  who  has  a  localizable  tumor  before  the  more  critical  osteo- 
plastic procedure  is  attempted.  The  operation,  furthermore,  may  be 
of  diagnostic  as  well  as  of  palliative  value,  as  has  been  pointed  out, 
for  occasionally  an  unsuspected  tumor  is  uncovered  in  the  temporal 
lobe  and  not  infrequently  a  puncture  of  the  ventricle  through  the  tem- 
poral convolutions  will  determine  the  presence  of  an  obstructive  hydro- 
cephalus, a  matter  which  may  be  of  considerable  localizing  value. 


SIEGICAL  C03IPLICATIOX8  EEST  LTIXG 

FE03I  SIPPIEATITE  MIDDLEEAE 

DISEASE. 

By  GEORGE  E.  SHAIMBAUGH,  ^I.D. 

SuppuR-^TiYE  disease  of  the  middle  ear  is  a  frequent  source  for 
serious  intracranial  disease,  such  as  thrombosis  of  the  lateral  sinus, 
meningitis  and  brain  abscess.  These  more  serious  complications 
develop,  as  a  rule,  as  the  sequel  of  disease  of  the  mastoid  process.  It 
is  important,  therefore,  that  the  surgeon  should  be  familiar  with  the 
clinical  symptoms  of  mastoid  disease  and  with  the  surgical  means  for 
its  relief.  Mastoid  disease  occurring  as  a  complication  of  an  acute 
otitis  media  takes  quite  a  different  course  and  requires  a  different 
surgical  treatment  than  when  it  occurs  as  a  complication  of  chronic 
suppuration  of  the  middle  ear.  For  this  reason  the  two  conditions 
should  be  considered  separately. 

MASTOIDITIS  IN  ACUTE  OTITIS  MEDIA. 

In  order  to  understand  the  clinical  significance  of  mastoid  disease 
complicating  an  acute  otitis  media,  it  is  necessary  for  one  to  have 
clearly  in  mind  a  few  fundamental  facts  in  the  anatomy  of  the  middle 
ear.  The  tympanic  cavity  is  but  one  of  a  series  of  pneiunatic  spaces 
in  the  temporal  bone  which  are  included  under  the  term  of  middle  ear. 
The  t^Tupanum  communicates  with  the  nasopharynx  by  a  canal  called 
the  Eustachian  tube.  It  communicates  also  by  means  of  an  ample 
passage  with  a  chamber  of  similar  size  located  at  the  base  of  the  mas- 
toid process  and  known  as  the  tympanic  antrum.  The  communicating 
passage  between  the  two  chambers  is  usually  referred  to  as  the  aditus. 
As  a  matter  of  fact,  the  tympanum  with  the  aditus  and  the  antrum 
constitute  one  large  chamber,  rather  than  three  separate  compart- 
ments. These  chambers,  vnth  the  Eustachian  tube,  exist  at  birth  and 
constitute  aU  there  is  of  middle-ear  cavities  at  that  age.  No  mastoid 
process  as  such  exists  at  that  period.  Before  the  child  has  reached 
maturity  the  mastoid  process  develops  and  as  it  develops  its  interior 
becomes  honeycombed  more  or  less  throughout  its  entire  extent  by 
pneumatic  cells  which  communicate  through  small  canaliculi  T\'ith  the 
tympanic  antrimi.  These  pneumatic  spaces  in  the  mastoid  process 
constitute  a  part  of  the  so-called  middle  ear,  just  as  do  the  t^Tiipanmn 
with  its  antrum  and  the  Eustachian  tube. 

Acute  inflammation  of  the  middle  ear  occurs  for  the  most  part  as 
VOL.  I— 29  (449) 


450  SUPPURATIVE  MIDDLE-EAR  DISEASE       ' 

the  result  of  infection  from  the  nasopharynx,  extending  up  through 
the  Eustachian  tube.  It  develops,  therefore,  as  a  rule,  as  the  sequel  of 
an  acute  pharyngitis,  an  acute  tonsillitis  or  of  an  acute  infection  of  the 
nasal  chambers.  An  acute  infection  of  the  middle  ear,  acute  otitis 
media,  always  involves  the  tympanic  antrum  as  well  as  the  tympanic 
cavity  proper,  since  the  two  constitute  one  chamber  with  only  a 
slightly  constricted  passage,  the  aditus,  between  them.  On  the  other 
hand,  the  extension  of  the  infection  to  the  pneumatic  spaces  of  the 
mastoid  process  is  not  a  necessary  complication  of  every  acute  otitis 
media.  It  occurs  much  more  frequently,  however,  than  the  clinical 
symptoms  over  the  process  would  indicate.  Two  facts  must  at  all 
times  be  kept  clearly  in  mind  in  the  treatment  of  acute  otitis  media: 
(1)  that  mastoiditis  with  marked  clinical  symptoms  occurs  very  fre- 
quently when  surgical  interference  is  not  called  for,  and  (2)  that 
mastoiditis  urgently  requiring  surgical  interference  often  develops  as  a 
complication  of  acute  otitis  media  when  no  outer  evidence  of  this  con- 
dition is  apparent  over  the  process.  It  is  apparent,  therefore,  that  the 
diagnosis  as  well  as  the  surgical  treatment  of  acute  mastoiditis  is  by  no 
means  always  a  simple  problem,  but  is  often  one  which  requires  a 
careful  study  of  the  case  if  the  proper  treatment  at  the  right  time  is  to 
be  carried  out. 

Sjrmptoms. — Let  us  inquire  now  into  the  various  clinical  manifes- 
tations of  mastoiditis  and  the  indications  which  call  for  surgical  inter- 
ference. An  acute  otitis  media  which  is  complicated  by  an  involve- 
ment of  the  pneumatic  spaces  of  the  mastoid,  as  a  rule,  develops  dis- 
tinct symptoms  over  this  process.  The  first  symptom  is  likely  to  be  the 
development  of  pain  over  this  region.  This  pain  may  be  slight  or  it 
may  become  very  severe,  requiring  a  sedative  if  the  patient  is  to  get 
any  sleep.  The  severity  of  the  pain  is  more  or  less  an  indication  of  the 
severity  of  the  reaction  in  the  process,  but  is  not  in  itself  an  indication 
for  surgical  interference  except  when  it  persists  after  the  drum  mem- 
brane has  been  opened  and  the  drainage  through  the  external  canal 
freely  established.  The  pain  from  mastoiditis  is  not  always  located 
over  the  process  itself  but  not  infrequently  is  referred  to  the  temporal 
region  of  the  same  side.  The  persistence  of  pain  in  this  region  in  con- 
nection with  an  acute  otitis  media  should  always  be  considered  as 
significant  as  when  it  is  centered  more  closely  over  the  process  itself. 

Tenderness  on  pressure  over  the  process  is  a  very  common  symptom 
of  acute  mastoiditis.  The  degree  to  which  the  surface  of  the  process 
becomes  sensitive  to  pressure  is,  however,  not  always  an  indication 
of  the  character  of  the  inflammatory  changes  taking  place  within. 
The  surface  of  the  process  may  be  exquisitely  sensitive  in  the  early 
stages  of  an  otitis  media  before  the  rupture  of  the  membrana  tympani, 
only  to  subside  spontaneously  a  few  days  after  the  drainage  of  the 
tympanum  has  been  established.  Tenderness  which  persists,  however, 
for  more  than  a  week  after  the  drum-membrane  has  been  opened  or 
especially  when  it  develops  a  week  or  more  after  the  ear  has  begun  to 
discharge,  is  much  more  significant  of  the  presence  of  changes  in  the 


MASTOIDITIS  IN  ACUTE  OTITIS  MEDIA  451 

mastoid  requiring  surgical  treatment  than  when  this  symptom  develops 
in  the  early  stages  of  the  otitis  media.  Tenderness  on  pressure  over  the 
mastoid  is  located,  as  a  rule,  over  the  antrum,  that  is,  close  to  the 
attachment  of  the  auricle,  just  behind  and  above  the  external  meatus  or 
at  the  tip  of  the  process,  where  especially  large  pneumatic  spaces  are 
often  located.  The  complete  absence  of  tenderness  over  the  mastoid 
is  no  indication  that  the  mastoid  is  not  diseased.  Indeed,  it  is  very 
common  to  find  a  large  abscess  cavity  in  the  mastoid  process  in  cases 
in  which  at  no  time  was  there  any  evidence  of  tenderness  on  pressure. 
Changes  in  the  soft  structure  over  the  process  have,  on  the  w^hole, 
about  the  same  significance  as  has  the  symptom  of  tenderness  on  pres- 
sure. When  these  changes,  such  as  slight  swelling  and  edema,  develop 
in  the  earliest  stages  of  the  otitis  media,  we  are  justified  in  attaching 
much  less  significance  to  them  than  when  they  develop  later,  that  is, 
after  the  ear  has  begun  to  discharge  for  a  week  or  more.  Edema  and 
swelling  developing  over  the  mastoid  before  the  drum-membrane  has 
been  opened  disappears  very  often  within  a  few  days  after  the  ear 
begins  to  discharge,  and  in  these  cases  the  mastoiditis  usually  goes  on  to 
spontaneous  recovery.  On  the  other  hand,  changes  in  the  soft  structures 
which  persist  for  a  week  or  more  after  the  ear  has  begun  to  drain  or 
where  these  changes  develop  after  the  drainage  has  been  established, 
as  a  rule,  indicate  a  softening  of  the  mastoid  bone,  w^hich  calls  for  sur- 
gical interference.  We  would  emphasize  again  the  fact  that  serious 
disease  in  the  mastoid  process  develops  not  infrequently  with  the 
formation  of  an  abscess  cavity,  constituting  a  serious  menace  to  the  life 
of  the  patient  through  the  development  of  intracranial  complications 
in  cases  in  which  no  changes  in  the  soft  structures  over  the  mastoid 
ever  appear.  As  a  matter  of  fact  the  development  of  changes  over  the 
mastoid  can  even  be  regarded  often  as  an  indication  of  a  less  dangerous 
type  of  mastoid  disease,  in  so  far  as  it  shows  a  tendency  for  the  abscess 
to  open  externally  rather  than  to  burrow  toward  the  brain  cavity. 
Serious  intracranial  complications,  however,  may  develop  simul- 
taneously with  the  occurrence  of  a  spontaneous  rupture  through  the 
cortex  of  the  mastoid.  A  fluctuation  of  the  swelling  over  the  process 
indicates  a  perforation  of  the  mastoid  cortex  and  the  development  of  a 
subperiosteal  abscess,  a  condition  rarely  allowed  to  occur  in  these 
days  except  in  young  children,  in  whom  the  existence  of  a  petro- 
squamosal  suture  through  the  antrum  allows  a  ready  extension  of 
infection  to  the  outer  surface  of  the  process.  The  best  way  to  detect 
the  early  evidence  of  changes  in  the  soft  structures  over  the  mastoid 
is  by  comparing  carefully  the  two  sides.  The  first  evidence  of  such 
change  will  be  the  obliteration  of  the  slight  depression  which  marks  the 
line  of  attachment  of  the  auricle.  It  is  only  by  comparing  the  two  sides 
that  one  can  recognize  the  first  evidence  of  obliteration  of  this  furrow. 
Swelling  occurring  in  the  neck  below  the  tip  of  the  process  is  not  uncom- 
mon in  adults  and  signifies  the  rupture  of  a  mastoid  abscess  on  the 
undersurface  of  the  mastoid  beneath  the  attachment  of  the  sterno- 
mastoid  muscle  or  the  rupture  of  a  pneumatic  cell  located  internal  to  the 


452  SUPPURATIVE  MIDDLE-EAR  DISEASE 

digastric  groove.    The  occurrence  of  such  swelling  in  the  neck  always 
constitutes  an  indication  for  a  mastoid  operation. 

Changes  frequently  occur  in  the  external  canal  which  give  a  clear 
indication  of  the  conditions  developing  within  the  mastoid.  The  most 
significant  is  a  distinct  sinking  in  the  soft  structures  along  the  upper 
posterior  wall  of  the  bony  meatus,  that  is,  in  the  depth  of  the  canal 
just  external  to  the  drum-membrane.  This  part  of  the  external  canal 
is  encroached  upon  (1)  by  the  tympanic  antrum  and  (2)  by  the  pneu- 
matic cells  of  the  mastoid.  A  swelling  along  the  upper  posterior  wall 
of  the  external  meatus  in  the  depth  of  the  canal  has  exactly  the  same 
significance  as  the  development  of  similar  changes  over  the  surface  of 
the  mastoid.  It  indicates,  as  a  rule,  the  development  of  a  softening  of 
the  bone  and  the  formation  of  a  mastoid  abscess,  a  condition  which 
requires  surgical  interference.  A  distinct  narrowing  of  the  fundus  of 
the  external  meatus  should  always  be  regarded  as  an  indication  of  a 
mastoid  disease,  which  is  pretty  sure  to  require  surgical  treatment. 

The  development  of  a  furuncle  in  the  external  canal  from  the  infec- 
tion of  hair  follicles  by  pus  coming  from  the  middle  ear  is  not  at  all 
uncommon  and  should  not  be  confused  with  a  swelling  occurring  as 
the  result  of  a  periostitis  secondary  to  a  mastoid  softening.  The 
furuncle  develops  in  the  outer  part  of  the  canal,  whereas  the  periostitis 
from  a  mastoid  abscess  develops  in  the  depths  of  the  canal.  The 
location  of  the  furuncle  is  usually  below  and  in  front,  whereas  the 
periostitis  is  always  along  the  upper  and  posterior  wall  of  the  canal. 

The  development  of  a  contraction  in  the  opening  made  in  the 
drum-membrane,  associated  with  a  more  or  less  pronounced  bulging  of 
the  upper  posterior  quadrant,  has  relatively  little  clinical  significance. 
Enlarging  the  opening  gives  but  a  little  temporary  gain,  as  invariably 
within  a  day  or  two  the  original  condition  has  returned. 

An  examination  of  the  discharge  from  the  external  canal  is  often  of 
great  value  in  determining  the  condition  within  the  mastoid.  A  pro- 
fuse discharge,  at  first  serosanguineous  but  later  distinctly  purulent 
and  lasting  from  a  few  days  to  a  couple  of  weeks,  is  the  rule  in  uncompli- 
cated cases  of  otitis  media.  When  a  profuse  discharge  continues,  with 
no  evidence  of  abatement  in  spite  of  proper  treatment  for  a  period  of 
three  weeks  or  more,  it  is  distinctly  significant  of  a  condition  within  the 
process  which  should  have  surgical  attention,  provided  this  discharge 
is  purulent  in  character  as  distinguished  from  a  mucopurulent  dis- 
charge. We  are  not  able  to  attach  so  much  importance  to  the  bacterial 
examination  of  this  discharge.  One  fact  stands  out  distinctly,  namely, 
that  the  cases  which  result  in  softening  of  the  bone,  that  is,*  the  cases 
which  are  most  likely  to  result  in  serious  complications  and  the  ones 
which  require  surgical  interference,  are  those  in  which  the  strepto- 
coccus is  the  prevailing  organism.  We  do  not  feel  that  the  bacterio- 
logical findings  alone  can  give  us  positive  indication  for  or  against  a 
mastoid  operation. 

Aside  from  subjective  and  objective  symptoms  of  mastoiditis  one 
usually  gets  some  assistance  from  an'examination  of  the  temperature 


MASTOIDITIS  IN  ACUTE  OTITIS  MEDIA  453 

chart  and  the  blood  analysis  in  determining  the  seriousness  of  the 
mastoid  disease.  The  temperature  in  an  uncomplicated  case  of  acute 
otitis  media  is  much  higher  in  children  than  in  an  adult.  In  the  latter, 
before  the  rupture  of  the  drum-membrane,  it  rarely  goes  above  101° 
or  at  most  102°  F.,  whereas  in  children  it  ranges  usually  1°  or  2° 
higher.  After  the  ear  has  begun  to  discharge  there  is,  as  a  rule,  a 
decided  drop,  even  in  cases  in  which  the  mastoid  is  more  or  less  severely 
involved.  In  children  this  drop  is  not  so  marked  as  in  the  adult,  and 
the  temperature  often  reaches  102°  for  several  days,  or  even  a  week  or 
two,  in  cases  which  go  on  to  a  spontaneous  recovery.  On  the  other 
hand  the  tendency  for  the  temperature  to  remain  up  for  a  week  or  more 
after  drainage  has  been  established,  especially  when,  after  a  temporary 
decline,  it  shows  a  tendency  to  go  up  after  the  ear  has  been  discharging 
for  a  week  or  more,  should  always  be  regarded  as  suspicious  of  a  con- 
dition which  will  eventually  require  surgical  assistance.  On  the  other 
hand,  in  adults,  especially,  it  is  not  uncommon  for  the  temperature  to 
show  very  slight  elevation  above  normal  in  cases  in  which  a  distinct 
mastoid  abscess  is  forming.  Every  case  of  acute  otitis  media  in  adults 
in  which  a  temperature  as  slight  as  99  °  persists  for  several  weeks  after 
the  ear  has  begun  to  drain  should  be  regarded  with  suspicion.  Even 
this  slight  elevation  may  not  be  noted  except  at  intervals  of  two  or 
three  days  in  cases  in  which  a  large  mastoid  softening  is  discovered  at 
the  operation.  A  chill  followed  by  a  sudden  rise  in  temperature,  occur- 
ring in  a  case  in  which  the  drainage  through  the  drum-membrane  has 
been  established,  is  always  on  ominous  sign,  for  it  rarely  occurs  in 
cases  which  do  not  require  operation. 

As  regards  the  blood  examination  the  increase  in  the  white  count 
after  the  ear  has  begun  to  discharge  is  not  very  marked,  especially  in 
adults,  even  with  the  development  of  mastoid  abscess.  The  white 
count  usually  does  not  go  above  10,000  to  12,000.  A  much  higher 
white  count  is  rather  significant.  It  is  found  in  cases  in  which  the 
mastoid  abscess  has  ruptured  through  the  cortex,  producing  an 
involvement  of  the  soft  structures,  or  into  the  tissues  of  the  neck. 
An  involvement  of  the  lateral  sinus  is  usually  heralded  by  a  marked 
increase  in  the  white  count. 

Diagnosis.- — ^Additional  information  of  the  condition  within  the 
mastoid  in  an  adult  can  be  gathered  by  transillumination  of  the  process 
and  by  examination  of  a  skiagraph.  Transillumination  is  carried  out 
by  introducing  a  small  lamp  into  the  external  canal.  If  the  pneumatic 
cells  of  the  mastoid  are  filled  with  pus  a  distinct  shadow  will  be  noted 
which  is  not  found  on  the  opposite  normal  side.  This  shadow  is  not  in 
itself  an  indication  that  a  condition  exists  in  the  mastoid  requiring 
an  operation.  Mastoiditis  with  pus  filling  the  mastoid  cells  is  a  fre- 
quent complication  of  an  acute  otitis  media,  whereas  relatively  few  of 
such  cases  require  a  mastoid  operation.  It  is  only  when  the  bony 
structure  undergoes  softening  with  the  formation  of  a  mastoid  abscess 
or  when  symptoms  occur  suggesting  an  intracranial  complication,  such, 
for  example,  as  a  chill  with  high  temperature  or  a  persistent  severe  pain 


454  SUPPURATIVE  MIDDLE-EAR  DISEASE 

that  an  operation  is  required.  As  a  matter  of  fact,  transillumination 
gives  us  no  clue  for  differentiating  between  a  mastoiditis  with  cells 
filled  with  pus  and  a  mastoiditis  with  breaking  down  of  bone.  It  is 
indeed  the  exceptional  case  in  which  transillumination  gives  any  infor- 
mation of  the  condition  within  the  mastoid  that  we  cannot  gain  by  an 
analysis  of  the  subjective  and  objective  symptoms  discussed  above. 

The  skiagraph  properly  made  is  often  able  to  show  just  the  differ- 
entiation we  desire  between  a  mastoid  process  filled  with  pus  and  one 
where  an  abscess  ca^'ity  is  forming.  A  cloudy  mastoid  has,  as  a  rule, 
no  more  significance  than  the  shadow  found  on  transillumination,  and 
is  not  in  itself  an  indication  that  a  disease  exists  requiring  surgical 
interference.  On  the  other  hand  a  well-made  skiagraph  will  often  show 
very  clearly  the  presence  of  softening  bone  and  formation  of  a  mastoid 
abscess  in  just  those  cases  in  which  the  physical  changes  over  the 
process  fail  to  give  a  satisfactory  clue  to  the  true  condition  going  on  in 
the  process. 

From  this  discussion  of  the  s^Tnptomatology  of  acute  otitis  media 
and  of  acute  mastoiditis  it  is  at  once  apparent  that  the  diagnosis  of 
the  condition  existing  in  the  mastoid,  and  especially  the  decision  of 
when  the  mastoid  operation  should  be  performed,  often  requires  a 
careful  exhaustive  examination  of  the  case. 

If  we  should  attempt  to  summarize  in  a  few  words  the  indications 
for  mastoid  operation  in  acute  otitis  media,  we  would  state  that  matter 
somewhat  as  follows: 

1 .  When  distinct  symptoms  of  a  mastoiditis  such  as  pain  and  tender- 
ness over  the  process  persist  without  evidence  of  abatement  for  a 
week  or  more  after  the  drum-membrane  has  been  opened  and  free 
drainage  established. 

2.  \Vhen  symptoms  develop  suggesting  an  impending  intracranial 
complication,  such  as  the  persistence  of  severe  mastoid  pain  or  the 
occurrence  of  a  chill  and  high  temperature. 

3.  ^^^len  a  swelling  develops  over  the  mastoid,  pushing  the  auricle 
forward,  or  when  a  swelling  develops  m  the  neck  below  the  tip  of  the 
mastoid. 

4.  "\Mien  a  distinct  sagging  of  the  upper  posterior  wall  of  the 
external  meatus  takes  place. 

5.  The  continuation  of  a  profuse  purulent  discharge  for  three  weeks 
or  more  after  the  drum-membrane  has  been  opened  and  proper  treat- 
ment carried  out. 

6.  WTien  the  skiagraph  shows  distinct  area  of  softening  in  the 
mastoid  process. 

Treatment. — ^The  earliest  operation  for  the  relief  of  acute  mastoiditis 
consisted  of  making  a  long  incision  through  the  postauricular  swelling 
cutting  through  the  periosteum.  This  method  of  operating  is  now 
discarded  except  occasionally  in  young  children.  Later  the  method  of 
making  an  opening  into  the  antrum  was  introduced.  This  operation 
was  based  on  the  idea  that  the  antrum  was  the  principal  seat  of  the 
trouble  and  that  the  condition  was  most  quickly  corrected  by  draining 


MASTOIDITIS  IN  ACUTE  OTITIS  MEDIA 


455 


the  antrum.  As  a  matter  of  fact,  it  is  not  the  infection  in  the  antrmn 
any  more  than  of  the  tympanum  proper  that  constitutes  a  mastoiditis, 
but  the  infection  in  the  mastoid  cells.  "While  it  is  true  that  by  making 
an  opening  through  the  cortex  into  the  antrum  a  degree  of  drainage  is 
established  for  the  infected  mastoid  cells,  a  better  method  is  to  attack 
directly  these  infected  cells.  The  actual  opening  into  the  antrum  may 
be  omitted  with  no  distinct  disadvantage  in  many  cases.  The  modern 
mastoid  operation  for  acute  mastoiditis  aims  at  as  complete  an  exen- 
teration of  the  infected  mastoid  cells  as  is  possible.  When  this  has  been 
accomplished  and  all  softened  bone  removed  from  the  mastoid  the  case 
is  pretty  sure  to  make  a  good  recovery. 

A  glance  at  the  several  types  of  mastoid  processes  shows  how  differ- 
ent this  operation  must  be  in  different  cases.  In  the  pneumatic  type, 
where  the  whole  process  is  filled  with  air  cells  (Fig.  183),  the  exenteration 


Fig.  183. — Section  through  pneumatic  type  of  mastoid,  showing  the  large  cells  along 
the  periphery  of  the  process  and  at  the  tip,  also  the  position  of  the  antrum  above  and 
posterior  to  the  external  auditory  canal. 


is  more  easily  accomplished  than  in  the  type  where  a  part  of  the  process 
remains  diploetic  (Fig.  184) .  The  cells  that  are  most  readily  overlooked 
are  those  which  lie  outside  the  confines  of  the  mastoid  process  proper, 
such  as  the  large  cell  which  sometimes  develops  internal  to  the  digastric 
groove  (Fig.  185),  the  cells  in  the  root  of  the  zygoma  above  the  external 
canal,  and  the  cells  which  develop  along  the  posterior  margin  of  the 
mastoid  process,  and  especially  the  cells  at  the  upper  posterior  angle 
An  incomplete  operation  on  the  mastoid,  leaving  the  deep-seated 
infected  cells  unopened,  is  a  frequent  cause  for  a  persistent  discharge 
from  an  unhealed  wound  and  for  the  development  of  fatal  intracranial 
complications.  It  behooves  the  surgeon,  therefore,  who  undertakes 
the  operation  for  the  relief  of  acute  mastoiditis  to  make  a  careful  study 
of  the  complicated  anatomy  of  the  temporal  bone,  in  order  that  he  may 
do  this  without  injury  to  the  important  anatomical  structures  which 


456 


SUPPrRATIVE  MIDDLE-EAR  DISEASE 


come  into  close  relation  w  ith  the  mastoid,  such  as  the  lateral  sinus,  the 
facial  nerve  and  the  horizontal  semicircular  canal. 


■nrMPANlCUM 

PROMLNENCeoF  hoR!20ntal  Canal 

FACIAL  CANAL 

ENESTRA   VESTISULl 


S    CAROTlCUS 


Fig.    184. — Section  through  mastoid  process  and  tympanum;  mastoid  process  showing 

but  few  air  spaces. 

In  performing  the  mastoid  operation  the  safest  instruments  have 
been  found  to  be  the  gouge,  bone  forceps  and  the  curette.  Because  of 
the  variation  in  the  course  of  the  lateral  sinus,  the  removal  of  the  outer 


INTRUM  TYMPANICL.'M 

JSUPERIOR  CANAL 
VESTIBULE 
MEATUS  ACUSTICUS    INTERNUS 


STOID    CELLS 


PROCESSUS  MAiTOIDEUS 


Fig.  185. — Section  through  temporal  bone,  showing  a  large  pneumatic  cell  internal  to 

digastric  groove. 


shell  of  the  mastoid  must  always  be  undertaken  with  great  caution. 
As  a  rule  the  sinus  is  located  fully  one-half  inch  from  the  surface  of  the 


MASTOID  DISEASE  IN  CHRONIC  OTITIS  MEDIA  457 

mastoid  and  three-fourths  of  an  inch  back  of  the  posterior  wall  of  the 
external  canal,  yet  it  is  not  uncommon  to  find  the  sinus  pushed  far 
forward,  so  that  it  lies  but  a  few  millimeters  from  the  external  canal  and 
close  under  the  outer  surface  of  the  mastoid.  The  first  step  in  the 
operation  is  the  complete  removal  in  thin  layers  of  the  outer  shell  of 
the  process  by  using  the  gouge  held  quite  flat  to  the  surface  of  the 
bone.  After  this  is  accomplished  one  penetrates  into  the  deeper  parts 
of  the  mastoid  in  the  same  cautious  manner  until  the  outlines  of  the 
lateral  sinus  are  clearly  exposed.  The  sinus  is  easily  recognized  by  the 
more  dense  character  of  its  bony  covering.  The  antrum  is  found  by 
working  in  the  depth  along  the  upper  posterior  wall  of  the  external 
meatus.  It  is  not  safe  to  penetrate  too  deeply  in  this  region,  for  if  one 
fails  to  differentiate  the  antrum  from  a  large  mastoid  cell  and  attempts 
to  penetrate  still  deeper  the  first  cut  of  the  chisel  in  the  floor  of  the 
antrum  may  open  into  the  labyrinth,  since  the  horizontal  semicircular 
canal  forms  the  floor  of  this  cavity  (Fig.  2) .  It  is  at  this  point,  too, 
where  the  greatest  danger  of  wounding  the  facial  nerve  lies,  since  the 
facial  canal  lies  exposed  to  injury  just  in  front  of  the  horizontal  canal. 
The  facial  canal  passes  along  the  posterior  wall  of  the  external  meatus, 
on  the  level  of  the  tympanic  cavity,  to  emerge  through  the  stylo- 
mastoid opening.  It  is  possible  to  injure  the  facial  nerve  even  in  doing 
the  simple  mastoid  operation  if  the  operator  is  not  thoroughly  familiar 
with  its  course  through  the  temporal  bone. 

It  is  not  our  practice  to  leave  the  mastoid  wound  wide  open  and 
packed  firmly  with  gauze,  as  was  formerly  done.  The  wound  is 
brought  together  both  above  and  below  and  through  a  rather  small 
opening  about  the  middle  of  the  incision  a  loose  drain  is  inserted. 
Ample  outer  dressing  is  then  applied.  The  latter  should  be  changed  as 
rapidly  as  it  becomes  soaked.  The  gauze  drain  need  not  be  disturbed 
for  five  or  six  days,  unless,  from  a  rise  in  the  temperature,  it  is  suspected 
that  proper  drainage  is  being  impaired.  With  this  method  it  requires 
from  three  to  six  weeks  for  the  wound  to  close.  Should  a  rather  profuse 
purulent  discharge  continue  longer  than  a  month  after  the  operation  it 
suggests  the  probability  of  further  extension  of  the  bone  disease  in  the 
depth  of  the  opening,  which  may  require  exenteration. 

MASTOID  DISEASE  IN  CHRONIC  SUPPURATIVE  OTITIS  MEDIA. 

Mastoid  disease  complicating  chronic  suppurative  otitis  media 
presents  problems  quite  different  from  those  of  mastoiditis  occurring  in 
connection  with  acute  otitis  media.  The  menace  from  serious  intra- 
cranial disease,  such  as  brain  abscess,  meningitis  and  sinus  thrombosis, 
is,  perhaps,  even  greater  than  in  acute  middle-ear  infection.  The 
selection  of  the  cases  of  chronic  suppurative  otitis  media,  which  are  a 
menace  from  the  more  frequent  but  relatively  harmless  cases,  and  the 
cure  of  the  former  by  proper  surgical  measures,  constitutes  one  of  the 
greatest  achievements  of  modern  otology.  There  was  a  time  when  it 
was  considered  dangerous  to  undertake  the  cure  of  chronic  discharge 


458  SUPPURATIVE  MIDDLE-EAR  DISEASE 

of  the  ear,  the  idea  being  that  this  discharge  constitutes  a  means  for 
the  escape  of  poisonous  material,  the  checking  of  which  was  Ukely  to 
bring 'on  some  intracranial  trouble.  When  it  became  known  that  a 
large  percentage  of  chronic  brain  abscesses,  not  to  mention  cases  of 
meningitis  and  of  sinus  thrombosis,  developed  as  a  sequel  to  an  appar- 
ently harmless  chronic  running  ear,  efforts  were  made  to  accomplish 
the  cure  of  these  cases  by  surgical  measures.  It  was  soon  found  that 
the  type  of  operation  which  sufficed  to  cure  the  mastoid  complications 
of  acute  otitis  media  would  not  cure  cases  of  chronic  otitis  media. 
Otologists  finally  elaborated  a  type  of  operation  which  would  cure  such 
cases.  The  working  out  of  this  problem,  as  well  as  the  clinical  differ- 
entiation of  the  cases  of  chronic  otitis  media  from  which  complications 
were  imminent  from  the  relatively  harmless  cases  of  chronic  middle-ear 
disease,  constitutes  one  of  the  best  examples  of  the  results  to  be  obtained 
by  concentration  of  effort,  which  is  only  possible  through  the  modern 
method  of  specialization  in  medicine.  The  solution  of  the  first  problem 
was  accomplished  through  the  elaboration  of  the  so-called  radical 
mastoid  operation.  The  solution  of  the  second  problem,  the  selection 
of  cases  requiring  surgical  treatment,  is  a  more  recent  achievement. 
There  was  a  period  after  the  radical  mastoid  operation  had  been  per- 
fected when  this  operation  was  considered  indicated  for  all  cases  of 
chronic  suppurative  otitis  media  which  could  not  be  cured  in  a  reason- 
ably short  period  by  local  measures  applied  to  the  tympanum.  At 
present  the  continuation  of  discharge  from  the  middle  ear  is  not  the 
criterion  determining  whether  the  case  should  be  subjected  to  an 
operation.  Many  cases  of  chronic  otitis  media  are  relatively  harmless 
affairs  from  which  serious  complications  need  not  be  feared.  So  long 
as  the  disease  involves  only  the  mucous  membrane  lining  the  middle- 
ear  chambers  no  complications  are  likely  to  develop.  In  this  respect 
chronic  otitis  media  is  not  unlike  acute  disease.  It  is  only  when  the 
process  begins  to  invade  the  temporal  bone  that  the  possibility  of  a 
serious  complication  arises.  As  a  matter  of  fact  the  transition  from  the 
simple  to  the  dangerous  type  rarely  takes  place  after  the  disease  has 
once  become  chronic.  The  invasion  of  the  bone  usually,  if  not  always, 
begins  during  the  early  acute  stages  of  the  otitis  media,  and  for  the 
most  part  such  cases  represent  those  which  should  have  had  the  simple 
mastoid  operation  performed  during  the  acute  period  at  the  onset  of 
the  otitis  media.  For  just  these  reasons  the  practice  of  operating  all 
cases  of  chronic  suppurative  otitis  medis,  which  could  not  be  cured  in  a 
short  period  by  local  means,  as  a  prophylactic  measure,  has  now  been 
discarded.  The  operation  is  reserved  for  those  cases  in  which  an 
involvement  of  the  bone  can  be  diagnosed. 

Diagnosis. — ^The  diagnosis  of  a  bone-invading  process  in  chronic 
suppurative  otitis  media  can  usually  be  accurately  determined  by  a 
careful  study  of  the  case.  Most  important  in  making  this  diagnosis  is 
the  character  of  the  discharge  from  the  middle  ear.  The  discharge 
that  is  found  in  a  case  in  which  the  mastoid  bone  is  diseased  has  usually 
a  peculiarly  offensive  odor.    The  discharge  from  any  chronic  running 


MASTOID  DISEASE  IX  CHRONIC  OTITIS  MEDIA  459 

ear  which  has  been  neglected  and  which  has  not  received  proper  local 
treatment  is  likely  to  be  more  or  less  foul.  In  the  simple  cases,  those  in 
which  the  bone  is  not  diseased,  this  odor  promptly  disappears  under 
simple  cleansing  treatment  with  antiseptic  solutions.  Not  so  the  cases 
complicated  by  disease  of  the  bone.  Here  the  odor  usually  persists  in 
spite  of  the  most  scrupulous  local  treatment. 

The  amount  of  the  discharge  is  not  an  essential  element,  although 
the  more  active  the  disease  process  the  greater  is  likely  to  be  the 
discharge.  Serious  intracranial  complications  frequently  occur  in 
cases  in  which  the  discharge  is  so  slight  that  the  patient  may  not  be 
aware  that  he  has  had  a  running  ear  for  many  years.  ^\Tien  wiping 
out  the  tympanum  with  a  pledget  of  cotton  in  such  cases  only  a  few 
strands  of  the  cotton  may  show  any  moisture.  In  such  cases  the  odor 
on  the  cotton  swab  can  be  detected  more  readily  than  can  the  actual 
presence  of  moisture.  In  other  cases  the  fundus  of  the  canal  appears 
quite  dry,  but  a  dry  crust  is  found  adherent,  especially  along  the  upper 
wall  of  the  canal,  the  undersurface  of  which  is  foimd  to  be  moist  and 
with  the  characteristic  odor  of  secretion  from  bone  disease. 

A  mucousy  discharge  from  the  ear,  no  matter  how  profuse,  is  not 
found  in  connection  with  a  bone-invading  process  except  as  it  may 
occasionally  be  caused  by  a  temporary  acute  exacerbation  involving 
the  mucous  membrane  of  the  middle  ear  in  cases  in  which  there  already 
exists  a  chronic  bone-invading  process  in  the  mastoid.  The  discharge 
from  a  disease  of  the  bone  is  granular  in  character,  as  distinguished 
from  the  more  mucousy  discharge  found  in  the  simple  cases.  This 
character  of  the  discharge  can  be  determined  by  examining  the  cotton 
swab  after  wiping  out  the  external  canal,  but  is  more  readily  recognized 
by  examining  the  washings  after  irrigation. 

An  important  clue  in  the  diagnosis  of  these  cases  can  be  obtained  by 
a  careful  examination  of  the  fundus  of  the  external  canal.  "WTien  an 
invasion  of  the  bone  is  going  on  the  perforation  of  the  drum-membrane 
is  almost  without  exception  marginal  in  character  and  is  located 
in  the  upper  posterior  quadrant,  with  a  distinct  erosion  of  the  bony 
canal  in  this  location.  Another,  though  less  frequent,  location  is  in 
Shrapnell's  membrane,  at  the  upper  pole  of  the  drum-membrane. 
The  marginal  perforation  may  rarely  be  located  in  the  anterior  part  of 
the  membrane.  The  size  of  the  perforation  has  very  little  significance. 
A  practically  complete  destruction  of  the  membrane  is  found  in  a  large 
percentage  of  the  harmless  cases  of  chronic  suppurative  otitis  media. 

The  presence  of  granulations  and  polyp  formations  in  the  fundus 
of  the  canal  has  not  the  serious  significance  that  has  often  been 
attributed  to  it.  It  is  only  when  there  is  a  tendency  for  these 
conditions  to  recur,  and  especially  when  they  are  associated  with 
other  evidences  of  a  bone-invading  process,  that  they  have  a  special 
significance. 

A  cholesteatomatous  formation  complicates  a  large  percentage  of  the 
cases  in  which  the  temporal  bone  is  involved.  This  condition  develops 
only  whenamarginalperforationin the  drum-membrane  exists.  A  central 


460  SUPPURATIVE  MIDDLE-EAR  DISEASE 

perforation,  no  matter  how  large,  is  never  complicated  by  an  invasion  of 
the  middle-ear  cavities  with  epidermis  from  the  external  canal  and  the 
formation  of  a  cholesteatoma.  The  existence  of  a  cholesteatoma  can 
be  diagnosed,  as  a  rule,  with  but  little  difficulty  by  the  detection  of  the 
characteristic  whitish  flakes  in  the  fundus  of  the  canal  and  especially 
in  the  washings  after  irrigation.  The  existence  of  a  cholesteatoma 
constitutes  the  chief  menace  in  most  of  the  more  dangerous  cases  of 
chronic  suppurative  otitis  media.  The  antrum  and  aditus,  as  well  as 
the  attic,  become  filled  with  the  material,  which,  by  exfoliation  of  the 
surface  membrane,  constantly  increases  in  size  and  produces  by  its 
pressure  a  constant  erosion  of  the  cavity  walls  until  some  vital  structure 
is  perforated.  If  this  perforation  takes  place  in  the  horizontal  canal 
in  the  floor  of  the  antrum  it  leads  usually  to  a  destruction  of  the 
labyrinth.  When  the  wall  of  the  lateral  sinus  is  invaded,  sinus  throm- 
bosis results.  If  the  process  causes  an  erosion  of  the  roof  of  the  antrum 
it  leads  eventually  to  a  fatal  meningitis  or  an  abscess  of  the  temporo- 
sphenoidal  lobe. 

Subjectively,  the  patient  has,  as  a  rule,  no  symptom,  even  in  cases 
in  which  the  bone  is  being  invaded,  except  when  an  acute  exacerbation 
of  the  chronic  process  sets  up  an  acute  otitis  media.  Aside  from  these 
cases,  pain,  indefinitely  located  but  restricted  to  the  affected  side  of  the 
head,  is  sometimes  observed,  and  when  present  is  quite  significant. 
Its  complete  absence  does  not  by  any  means  exclude  the  possibility 
of  a  dangerous  disease  in  the  mastoid. 

Treatment. — ^The  indications  for  a  radical  mastoid  operation  in 
cases  of  chronic  suppurative  otitis  media  are  restricted  to  those  cases 
in  which  an  examination  discloses  evidences  of  a  cholesteatoma  or  of 
bone-invading  disease.  In  addition  should,  of  course,  be  included 
those  cases  in  which  an  acute  exacerbation  brings  on  symptoms  of 
an  acute  mastoiditis  as  well  as  the  cases  presenting  symptoms  of  an 
intracranial  complication. 

The  radical  mastoid  operation  is  a  much  more  difficult  undertaking 
than  is  the  simple  mastoidectomy  which  is  performed  for  the  cure  of 
the  mastoiditis  complicating  acute  otitis  media.  It  is  important  before 
undertaking  this  operation  to  bear  in  mind  the  fact  that  in  chronic 
suppurative  otitis  media  requiring  a  radical  mastoid  operation  no  pneu- 
matic mastoid  process  exists,  the  reason  being  that  in  most  cases  the 
suppurative  middle-ear  disease  begins  in  early  childhood  before  the 
pneumatization  of  the  mastoid  has  taken  place  and  the  disease  in  the 
antrum  prevented  the  normal  development  of  mastoid  cells.  In  other 
cases  in  which  the  otitis  media  began  after  the  process  had  become 
pneumatic,  by  a  slow  process  of  osteosclerosis  these  cells  have  become 
obliterated.  All  that  exists  of  the  middle-ear  chambers  in  these  cases 
is  the  tympanum  with  its  attic  and  the  tympanic  antrum.  The  latter, 
as  a  rule,  is  a  much  contracted  chamber.  The  simple  opening  and  clean- 
ing out  of  the  antrum  will  not  suffice  to  cure  these  chronic  cases,  because 
the  disease  process  also  involves  the  aditus  as  well  as  the  attic.  The 
radical  mastoid  operation  consists  of  an  exenteration  not  alone  of  the 


MASTOID  DISEASE  IN  CHRONIC  OTITIS  MEDIA  461 

antrum  but  of  the  aditus  and  attic,  as  well  as  of  the  tympanum  and  the 
tympanic  orifice  of  the  Eustachian  tube,  followed  by  a  plastic,  which 
aims  to  secure  an  epidermization  of  the  common  chamber  made  of 
these  cavities. 

The  first  step  is  to  secure  an  opening  into  the  antrum.  This,  because 
of  the  usually  contracted  size  of  the  cavity  and  the  sclerosed  mastoid 
bone  through  which  the  opening  has  to  be  made,  is  a  difficult,  pains- 
taking procedure.  With  the  bony  meatus  freely  exposed  and  the  loca- 
tion of  the  antrum  just  above  and  behind  the  wall  of  the  canal  in  mind 
the  opening  of  the  antrum  is  accomplished  by  making  a  funnel-shaped 
opening  through  the  mastoid  process  with  the  apex  always  directed 
along  the  upper  posterior  bony  meatus  and  the  outer  opening  broad  and 
flat.  The  next  step  after  the  antrum  has  been  entered  is  to  remove 
the  posterior  wall  of  the  bony  external  meatus.  This  will  serve  to  lay 
open  the  aditus.  After  that  the  outer  wall  of  the  attic  is  taken  away, 
followed  by  a  careful  exenteration  of  the  tympanic  cavity  and  of  the 
t^Tiipanic  orifice  of  the  Eustachian  tube. 

The  operation  should  not  be  undertaken  on  the  living  without 
ample  experience  on  the  cadaver.  There  are  a  number  of  important 
anatomical  structures  that  may  readily  be  injured  unless  one  is  quite 
familiar  with  the  technic  of  the  operation  and  of  the  anatomical 
relations  of  the  temporal  bone.  The  danger  of  wounding  the  lateral 
sinus  in  making  the  opening  into  the  antrum  is  the  same  as  in  per- 
forming the  simple  mastoid  operation.  It  is  after  the  antrum  has  been 
entered,  however,  that  the  chief  danger  of  injuring  important  anatomi- 
cal structures  arises.  It  is  important,  therefore,  that  the  outer  opening 
into  the  antrum  should  be  made  ample  so  that  one  can  see  clearly  the 
relations  in  the  bottom  of  the  opening.  Because  of  the  small  size  of  the 
antrum  it  is  a  very  easy  matter  to  chisel  too  deeply  and  to  chip  off  a 
piece  in  the  floor  of  this  cavity.  Such  a  mistake  will  usually  open 
directly  into  the  labyrinth  by  breaking  through  the  horizontal  canal, 
which  forms  the  bottom  of  the  antrum  as  one  enters  this  cavity  through 
the  mastoid  process. 

In  removing  the  posterior  wall  of  the  bony  meatus  there  is  danger  of 
injuring  the  facial  nerve  which  courses  down  along  the  posterior  margin 
of  the  tympanic  cavity.  At  the  level  of  the  aditus  this  nerve  lies 
on  the  same  plane  with  the  inner  wall  of  the  tympanum,  but  toward 
the  floor  of  the  tympanic  cavity  it  courses  out  perceptibly  along  the 
posterior  wall  of  the  external  canal.  For  this  reason  the  posterior  bony 
meatus  must  be  removed  with  great  care.  On  the  level  of  the  aditus 
the  whole  of  the  bony  wall  can  be  taken  off,  but  as  one  approaches  the 
floor  of  the  tympanum  more  and  more  of  a  ridge  must  be  preserved  to 
protect  the  facial  nerve  from  injury.  The  proper  flattening  of  this 
facial  ridge  is  one  of  the  delicate  parts  of  the  mastoid  operation.  It  is 
very  important  that  as  little  of  the  ridge  as  possible,  for  the  safety  of  the 
facial  nerve,  should  be  left  standing  (Fig.  5). 

The  removal  of  the  outer  wall  of  the  attic  is  also  fraught  with  danger 
to  the  facial  nerve,  as  the  canal  for  this  nerve  passed  horizontally 


462 


SUPPURATIVE  MIDDLE-EAR  DISEASE 


through  the  tympanum  just  internal  to  the  free  edge  of  the  attic  cover- 
ing. In  curetting  out  the  t\Tnpanum,  which  has  to  be  scrupulously 
done  to  get  rid  of  all  of  the  mucous  membrane  lining  this  chamber  as 
well  as  of  any  diseased  bone,  caution  must  be  observed  not  to  disturb 
the  stapes  in  the  oval  window.  In  curetting  the  floor  of  the  tympanum 
one  should  not  lose  sight  of  the  fact  that  the  bulb  of  the  jugular  may 
lie  exposed  in  this  region  or  be  covered  by  only  a  delicate  bony  shell 
(Fig.  186).  Again,  in  curetting  out  the  tATnpanic  orifice  of  the  Eusta- 
chian tube  the  close  proximity  of  the  internal  carotid  along  the  mesial 
aspect  of  this  canal  requires  caution,  lest  the  instrument  breaks  through 
its  thin  bony  covering. 


FENESTRA   VESTIBULI 
FACIAL  CANAL 

PROMINEMCE   OF    HORIZONTAL   CA^ 

ANTRUM    T>MPAN1CU^^ 


LBUS    JUGULARis 


Fig.   186. — Section  through  temporal  bone   passing  through  external  canal,  tympanic 
caA-ity,  and  internal  meatus,  showing  relation  of  jugular  bulb  to  floor  of  tympanum. 


The  principle  in  making  the  plastic,  the  aim  of  which  is  to  secure 
epidermization  of  the  combined  middle-ear  cavities  left  after  the 
completion  of  the  bone  work,  is  the  splitting  of  the  membranous 
external  canal,  making  two  flaps.  The  upper  flap  is  pushed  into  the 
upper  part  of  the  bone  cavity  while  the  lower  flap  is  approximated  to 
the  lower  wall.  Both  flaps  may  be  anchored  with  catgut  sutures. 
From  the  external  meatus  a  narrow  strip  of  gauze  is  now  introduced, 
which  holds  these  flaps  securely  in  place.  The  incision  back  of  the  ear 
is  then  brought  together  throughout  its  entire  extent.  The  outer  dres- 
sings should  be  removed  as  often  as  they  become  soiled,  but  the  pack- 
ing in  the  external  canal  should  not  be  disturbed  for  about  a  week.  The 
subsequent  careful  repacking  with  gauze  strips,  the  cauterizing  of  the 
exuberant  granulations,  all  require  skill,  in  order  to  bring  about  the 
epidermization  of  the  bony  cavity.  Xo  exact  period  can  be  stated 
of  the  time  required  until  the  healing  is  complete,  but,  as  a  rule,  very 
little  attention  is  required  after  from  three  to  six  weeks. 


COMPLICATIONS  OF  MASTOIDITIS 


463 


COMPLICATIONS  OF  MASTOIDITIS. 

The  more  serious  complications  of  suppurative  otitis  media  develop, 
as  a  rule,  secondary  to  a  mastoiditis,  but  they  may  also  occur  as  the 
result  of  direct  extension  from  disease  in  the  tympanum  in  cases  in 
which  none  of  the  clinical  evidences  of  a  mastoiditis  exist. 

Infectious  Labyrinthitis. — Extension  of  infection  to  the  internal 
ear  is  a  complication  of  both  the  acute  and  chronic  forms  of  suppurative 
otitis  media.  A  marked  depression  of  the  function  of  hearing  is  usually 
one  of  the  characteristic  symptoms  of  sucli*  an  extension.  This  depres- 
sion of  the  hearing  function  is  likely  to  prove  the  most  serious  symptom 
for  the  patient,  as  it  frequently  means  a  permanent  loss  of  this  impor- 
tant sense.    The  labyrinth  of  the  ear  includes  the  end-organs  not  alone 


RIDGE  OF    HORIZONTAL  CfiJ^AV 


SINUS    LATERAli. 


RIDGE   OF  FACIAL  C, 


/v./ 


CANALIS   CAPOTICUS 


Fig.   187. — The  appearance  of  the  temporal  bone  after  the  bone- work  for  the  radical 
mastoid  operation  has  been  completed. 


of  hearing  but  others  which  play  an  important  part  in  preserving  the 
body  equilibrium.  The  symptom  which  causes  the  most  immediate 
annoyance  to  the  patient  does  not  arise  from  the  destruction  of  the 
hearing  function,  but  comes  from  the  disturbances  of  the  end-organs 
of  equilibrium.  These  end-organs  are  located  in  the  semicircular  canals 
and  in  the  vestibule.  Any  sudden  involvement  of  this  mechanism, 
such  as  results  from  an  extension  of  infection  from  suppurative  otitis 
media,  produces  a  violent  attack  of  vertigo  associated  usually  with 
intense  nausea  and  vomiting.  It  is  these  symptoms  of  nausea,  vomiting 
and  vertigo  that  constitute  the  chief  complaint  of  patients  suffering 
from  an  acute  labyrinthitis.  Very  little  complaint  is  made  of  the 
impairing  of  hearing,  especially  when  one  ear  remains  normal,  until 
later,  when  the  vertigo  subsides.    The  duration  of  the  vertigo  is  always 


404  SUPPURATIVE  MIDDLE-EAR  DISEASE 

temporary,  for  even  when  it  is  caused  by  a  complete  destruction  of  the 
function  of  the  internal  ear  it  may  not  persist  longer  than  a  couple  of 
weeks. 

We  cannot  enter  into  a  discussion  of  all  the  phenomena  associated 
with  an  extension  of  infection  to  the  internal  ear.  We  aim  rather  to 
make  such  a  statement  of  these  symptoms  that  the  surgeon  may  be 
able  to  recognize  what  he  is  dealing  with.  We  speak  of  three  types  of 
infectious  labyrinthitis  complicating  suppurative  disease  of  the  middle 
ear:  a  circumscribed  labyrinthitis;  a  diffuse  serous  labyrinthitis;  and 
a  diffuse  suppurative  labyrinthitis. 

The  circumscribed  form  of  labyrinthitis  is  a  complication  only  of 
chronic  mastoiditis.  It  is  the  result  of  an  erosion  of  a  bone-invading 
process  through  the  capsule  of  the  labyrinth.  This  erosion  takes  place 
usually  in  the  horizontal  canal,  where  this  structure  lies  exposed  in  the 
floor  of  the  aditus  ad  antrum.  It  may  rarely  penetrate  the  superior 
canal  where  this  lies  exposed  on  the  inner  wall  of  the  aditus.  The 
development  of  the  fistula  into  the  labyrinth  is  by  a  slow  process  of 
erosion  of  the  bony  capsule  and  results  in  an  involvement  of  the  mem- 
branous structures  in  the  inner  ear  only  in  the  immediate  region  of  the 
bony  fistula.  Here  the  process  becomes  circumscribed,  walled  off  from 
the  remainder  of  the  labyrinth  by  protective  granulations.  The  infec- 
tion may  in  rare  cases  eventually  break  through  these  granulations 
and  give  rise  to  a  diffuse  infection  of  the  internal  ear. 

Very  few  symptoms  are  noted  as  long  as  the  disease  remains  cir- 
cumscribed to  the  region  of  the  bony  fistula.  The  presence  of  such  a 
fistula  can  usually  be  readily  diagnosed  by  making  compression  of  air 
in  the  external  meatus,  either  by  means  of  a  Politzer  bag  or  even  by 
pressing  the  finger  in  the  external  meatus.  Such  compressiom  will  cause 
a  depression  of  the  soft  structures  closing  the  opening  in  the  bone  and 
result  in  a  movement  of  the  endolymph  in  the  semicircular  canal.  If 
the  fistula  is  in  the  horizontal  canal  the  eyes  will  be  seen  to  move  in 
the  horizontal  plane  toward  the  opposite  side  and  then  jerk  quickly 
back  toward  the  affected  side,  thus  producing  a  characteristic  hori- 
zontal nystagmus.  When  suction  is  made  in  the  external  meatus  this 
movement  of  the  eye  is  reversed.  Should  the  fistula  be  located  in  the 
superior  canal,  compression  of  air  in  the  external  meatus  will  produce 
a  rotary  nystagmus. 

Diffuse  labyrinthitis  is  a  complication  of  the  acute  as  well  as  of  the 
chronic  suppurative  otitis  media.  It  is  a  more  serious  complication 
not  alone  because  of  the  danger  of  a  permanent  destruction  of  the 
function  of  hearing,  but  also  because  of  the  risk  of  an  intracranial 
extension  setting  up  a  meningitis  or  a  cerebellar  abscess.  The  milder 
cases  of  diffuse  labyrinthitis  are  the  result  of  a  serous  disease  of  the 
internal  ear,  while  the  more  severe  cases  are  caused  by  a  suppura- 
tive process  invading  the  labyrinth.  It  is  not  always  possible  to 
make  a  sharp  differentiation  clinically  between  the  serous  and  the  sup- 
purative processes.  Of  this,  however,  we  may  be  sure:  that  any  process 
which  causes  only  a  partial  suppression  of  the  function  of  the  labyrinth, 


COMPLICATIONS  OF  MASTOIDITIS  465 

leaving  either  a  remnant  of  hearing  or  of  the  function  of  the  semi- 
circular canals,  is  always  the  serous  type  of  labyrinthitis.  On  the  other 
hand  a  diffuse  suppurative  labyrinthitis  always  results  in  a  complete 
and  permanent  destruction  of  the  function  of  the  labyrinth.  Clinically 
it  is  of  great  importance  to  make  this  diagnosis  between  the  serous  and 
suppurative  processes,  because  the  suppurative  form  not  infrequently 
leads  to  a  fatal  intracranial  complication,  which  may  be  prevented  by  a 
timely  operation  providing  adequate  drainage  for  the  infection  in  the 
internal  ear,  whereas  the  serous  form  rarely  if  ever  produces  such  a 
complication.  The  diagnosis  is  not  always  possible  for  the  reason  that 
the  more  severe  cases  of  serous  labyrinthitis  may  produce  a  complete 
suppression  of  the  function  of  hearing  as  well  as  of  the  semicircular 
canals.  From  the  disturbances  of  function  caused  by  the  serous  dis- 
ease of  the  labyrinth  it  is  always  possible  for  a  patient  to  make  a  com- 
plete recovery.  The  depression  of  function  resulting  from  an  acute 
invasion  of  the  labyrinth,  disturbs  the  normal  equilibrium  and  pro- 
duces intense  vertigo,  and  a  rotary  nystagmus  with  the  quick  move- 
ment of  the  eyes  directed  to  the  opposite  side.  This  is  always  a  tem- 
porary phenomenon,  for  even  in  cases  in  which,  as  a  result  of  a  diffuse 
suppurative  labyrinthitis,  there  is  a  complete  destruction  of  function 
in  the  affected  ear  the  vertigo  and  nystagmus  disappear  usually  within 
two  or  three  weeks. 

Treatment. — An  operation  on  the  labyrinth  is  undertaken  to  prevent 
the  development  of  an  intracranial  complication  by  extension  to  the 
cerebellar  cavity  or  because  of  such  an  extension.  The  operation  is 
undertaken  only  in  cases  of  diffuse  suppurative  labyrinthitis,  since 
these  are  the  only  ones  which  produce  these  serious  complications. 
Since  the  diagnosis  of  a  diffuse  suppurative  from  a  serous  labyrinthitis 
cannot  always  be  made,  we  restrict  the  labyrinth  operation  first  to 
those  cases  in  which  careful  functional  tests  disclose  a  complete  sup- 
pression of  function,  not  alone  of  hearing  but  of  the  semicircular  canals 
in  the  affected  ear.  Of  these  cases  only  those  are  selected  for  a  laby- 
rinth operation  in  which  clinical  symptoms  exist,  requiring  either  a 
simple  or  a  radical  mastoid  operation,  or  where,  in  the  absence  of  such 
indications,  sATiiptoms  of  an  intracranial  complication  from  an  exten- 
sion of  the  labyrinth  infection  have  already  begun  to  appear.  The 
operation  on  the  labyrinth  is  always  preceded  by  a  radical  mastoid. 
The  effort  is  then  made  to  secure  adequate  drainage  from  the  laby- 
rinth by  chiselling  away  the  promontory,  beginning  at  the  lower 
margin  of  the  oval  window.  A  second  opening  into  the  vestibule  is 
then  undertaken  from  behind  the  facial  ridge.  The  horizontal  canal  is 
opened  where  this  structure  lies  exposed  in  the  bottom  of  the  antrum. 
The  canal  is  then  followed  fon\"ard  until  the  vestibule  is  freely  open 
from  this  side.  This  much  can  be  readily  carried  out  by  anyone  suffi- 
ciently familiar  with  the  anatomy  of  the  temporal  bone  to  warrant  his 
undertaking  a  radical  mastoid  operation.  It  is  possible  also  to  accom- 
plish a  more  complete  exenteration  of  the  labyrinth,  and  this  is  the 
operation  of  choice,  especially  where  symptoms  of  an  intracranial 
complication  already  exist. 

VOL.  I — 30 


466  SUPPURATIVE  MIDDLE-EAR  DISEASE 

Sinus  Thrombosis. — The  most  common  of  the  more  serious  com- 
phcations  of  suppurative  otitis  media  is  thrombosis  of  the  lateral 
sinus.  This  venous  channel  courses  along  the  inner  aspect  of  the 
mastoid  process  and  is  therefore  exposed  to  extension  of  disease  from 
the  mastoid  in  both  the  acute  and  chronic  otitis  media.  There  are  a 
few  clinical  facts  to  be  kept  in  mind  in  diagnosing  the  presence  of  a 
thrombosed  sinus  and  in  determining  the  proper  course  of  treatment 
for  this  condition. 

Symptoms. — The  symptoms  of  sinus  thrombosis  are,  as  a  rule,  so 
characteristic  that  one  experiences  little  difficulty  in  making  a  diagnosis. 
The  s^■mptoms  are  those  of  thrombosis  of  any  large  vein.  There  is  a 
sudden  rise  of  temperature  to  104°  or  even  106°  F.,  preceded,  as  a  rule, 
by  a  more  or  less  severe  chill,  and  followed  in  a  few  hours  by  a  sudden 
drop  to  normal  or  lower,  associated  with  a  profuse  perspiration.  This 
phenomenon  may  repeat  itself  as  often  as  once  each  day  or  the  attacks 
may  be  separated  by  intervals  of  several  days.  In  the  interval  between 
the  attacks  the  temperature  may  remain  normal  and  the  patient  feels 
quite  well.  An  examination  of  the  blood  will  disclose  a  marked  leuko- 
cytosis and  blood  cultures  will  disclose  a  bacteremia.  The  clinical 
symptoms  are  not  unlike  those  produced  by  malaria,  from  which  the 
disagnosis  may  be  made  by  an  examination  of  the  blood  for  the  Plas- 
modium. On  the  other  hand  it  is  not  so  uncommon  when  operating 
on  a  case  where  these  symptoms  have  begun,  to  discover  no  tangible 
evidence  of  sinus  thrombosis.  The  explanation  here  may  be  that  the 
svTnptoms  have  been  caused  by  the  escape  of  minute  emboli  into  the 
blood  stream  from  thrombosed  veins  in  the  mastoid  process.  In  such 
cases  the  sAinptoms  disappear  promptly  after  the  infection  has  been 
eradicated  from  the  mastoid. 

It  is  not  such  an  uncommon  experience  to  discover  in  the  course  of  a 
mastoid  operation  a  solidly  thrombosed  sinus  in  a  case  w^here  there  has 
been  no  s^Tnptom  suggesting  such  a  complication.  The  explanation 
here  seems  to  be  that  as  the  infection  from  the  mastoid  begins  to  in^■ade 
the  sinus  wall  the  sinus  becomes  occluded  by  a  protective  thrombus, 
and  where  the  process  of  repair  is  active  enough  the  bacterial  invasion 
of  the  thrombosed  sinus  is,  for  the  time  at  least,  inhibited.  In  such 
cases  there  is  evidently  nothing  to  be  gained  by  a  removal  of  this  pro- 
tective thrombus.  The  important  thing  is  to  eradicate  the  focus  of 
infection  in  the  mastoid  process.  Unnecessary  manipulations  in 
removing  the  thrombus  may  even  be  harmful  by  increasing  the  danger 
of  systemic  infection.  How  far  this  conservative  policy  may  be 
followed  to  advantage  in  other  cases  of  thrombosis  where  the  char- 
acteristic sATnptoms  have  appeared  is  a  question  about  which  there 
is  still  a  difference  of  opinion.  In  cases  in  which  the  breaking  down  of 
the  thrombus  has  taken  place  and  the  sinus  is  found  filled  with  pus  the 
ligation  of  the  jugular  in  the  neck  followed  by  as  thorough  a  removal 
of  the  infected  thrombus  as  is  possible  seems  justified.  But  where  the 
thrombus  has  not  disintegrated  and  no  palpable  e^■idence  of  softening 
can  be  detected  it  mav  often  be  to  the  best  interests  of  the  case  not  to 


COMPLICATIONS  OF  MASTOIDITIS  467 

do  more  than  a  thorough  exenteration  of  the  diseased  mastoid  and  a 
sHtting  open  of  the  sinus  to  provide  adequate  drainage,  allowing  the 
protective  clots  to  remain  rather  than  to  remove  them  only  to  have 
them  replaced  by  a  fresh  thrombus. 

Treatment. — An  operative  exposure  of  the  lateral  sinus  is  always 
preceded  by  a  simple  mastoid  exenteration  in  acute  otitis  media,  and 
the  radical  operation  in  cases  where  the  trouble  has  developed  as  a 
complication  of  chronic  suppurative  otitis  media.  The  bony  wall  of 
the  sinus  is  removed  by  first  making  an  opening  with  a  gouge  held 
quite  flat,  so  as  not  to  enter  the  sinus.  As  large  an  exposure  as  desired 
is  then  readily  made  with  suitable  rongeur  forceps.  The  color  and 
normal  luster  of  the  sinus  is  usually  altered  when  the  vessel  is  throm- 
bosed. \^Tien  a  solid  thrombus  exists  this  can  be  detected  by  pressure 
over  the  sinus  with  the  finger.  When  one  is  in  doubt  an  aspirating 
needle  may  be  introduced,  the  needle  being  held  as  flat  as  possible, 
so  as  to  make  a  slanting  puncture  through  the  sinus  wall.  The  presence 
of  a  parietal  thrombus,  one  only  partially  occluding  the  sinus,  may  not 
be  detected  by  this  method.  ^Mien  the  thrombus  is  found  broken 
down  the  wall  of  the  sinus  should  be  freely  slit  and  with  a  dull  curette 
only  the  softened  part  of  the  thrombus  removed,  care  being  taken  not 
to  disturb  the  solid  thrombus  at  either  end.  In  some  cases  in  which 
the  sjTnptoms  of  sepsis  have  been  well  established  and  the  sinus  is 
found  filled  with  pus  the  more  radical  procedure  of  ligation  or  removal 
of  the  jugular  followed  by  as  thorough  removal  as  possible  of  the 
infected  thrombus  may  be  resorted  to.  "When  the  sjonptoms  clearly 
point  to  thrombosis  and  no  thrombus  is  discovered  in  the  sinus  it  is 
probable  that  the  bulb  of  the  jugular  is  thrombosed.  If  after  pressing 
the  blood  out  of  the  sinus  and  tamponing  the  upper  end  by  placing,  a 
gauze  compress  between  the  sinus  and  the  bony  wall  it  is  seen  that  the 
sinus  remains  collapsed  one  can  feel  quite  sure  that  the  bulb  is  throm- 
bosed. The  ligation  of  the  jugular  in  the  neck  with  its  partial  or  com- 
plete excision  should  precede  an  effort  to  dislodge  the  clot  in  the  bulb. 

Otitic  Meningitis. — Meningeal  involvement  in  suppurative  otitis 
media  is  not  an  uncommon  complication  in  both  the  acute  and  chronic 
forms  of  middle-ear  disease.  By  far  the  most  frequent  t}n[)e  is  a  cir- 
cimiscribed  involvement  of  the  dura — a  pachAineningitis.  This  is 
found  in  the  middle  brain  fossa  where  the  dura  comes  in  contact  with 
the  roof  of  the  middle-ear  chambers.  But  more  frequently  is  the 
posterior  fossa  involved  in  the  form  of  a  perisinus  infection.  "^^Tien  the 
outer  surface  of  the  dura  is  involved  we  speak  of  an  extradural  menin- 
gitis, and  when  the  drainage  is  interfered  with  this  condition  is  always 
associated  with  an  extradural  abscess.  Less  frequently  the  inner  aspect 
of  the  dura  is  the  seat  of  inflammation,  forming  the  so-called  subdural 
abscess. 

An  external  pachjTneningitis  without  the  formation  of  an  extradural 
abscess  runs  its  course  without  sjTaptoms,  and  even  when  an  extra- 
dural abscess  exists  the  only  sjTxiptom  may  be  a  more  or  less  persistent 
headache  unless  the  abscess  is  of  unusual  size,  when  it  may  produce 


468  SUPPURATIVE  MIDDLE-EAR  DISEASE 

pressure  sjinptoms  not  unlike  those  of  a  brain  abscess.  The  subdural 
abscess  sooner  or  later  gives  rise  to  symptoms  characteristic  of  a  true 
brain  abscess.  The  diagnosis  of  a  pach^Tiieningitis  can  sometimes  be 
surmised  from  the  continued  severe  headache  in  the  absence  of  other 
symptoms  of  intracranial  disease.  This  condition  is,  however,  often 
uncovered  unexpectedly  in  the  course  of  an  operation  on  the  mastoid. 
"When  there  is  a  persistent  headache  and  a  purulent  discharge  from  the 
unhealed  mastoid  wound  after  a  mastoid  exenteration  in  acute  otitis 
media  an  extradural  abscess  above  the  roof  of  the  middle-ear  chambers, 
and  especially  at  the  extreme  outer  upper  angle  of  the  mastoid,  is 
frequently  found. 

An  inflammation  of  the  subarachnoid  space  between  the  arachnoid 
and  the  pia  produces  the  so-called  leptomeningitis.  This  may  result 
from  direct  contact  with  an  inflamed  dura,  but  it  also  develops  from 
hinph  or  bloodvessel  communications  with  the  middle  ear  as  well  as 
by  extension  from  infection  in  the  labyrinth.  This  form  of  meningitis 
may  be  circumscribed  or  diffuse,  and  either  form  may  be  serous  or 
purulent  in  character.  There  is  no  fundamental  difference  between 
the  serous  and  purulent  forms  of  meningitis.  Both  are  infectious  in 
origin.  The  transition  is  a  gradual  one,  the  difference  being  due  prin- 
cipally to  the  varying  virulence  of  the  infectious  agent.  Both  forms 
may  have  a  fatal  termination,  and  even  the  diffuse  purulent  menin- 
gitis occasionally  recovers. 

The  course  of  meningitis  varies  widely.  In  a  few  fulminating  cases 
the  disease  ends  fatally  within  one  or  two  days.  The  purulent  form 
usually  terminates  fatally  in  the  course  of  the  first  week,  but  may  last 
for  three  or  four  weeks.  There  is  an  intermittent  form  of  meningitis 
which  is  sometimes  secondary  to  labyrinth  suppuration,  where  the 
attacks  with  the  characteristic  s;sTiiptoms  of  meningitis  may  be  sepa- 
rated by  intervals  of  months  or  even  years,  until  the  patient  finally 
succumbs  to  a  diffuse  purulent  meningitis.  The  autopsy  in  such  cases 
discloses  the  evidences  of  preceding  inflammation.  That  patients 
recover  from  meningitis  of  otitic  origin  is  well  known.  Formerly  it 
was  supposed  that  only  the  serous  cases  could  recover.  It  is  now  proved 
beyond  a  doubt  by  evidence  of  pus  found  on  incising  the  dura  that 
cases  of  purulent  diffuse  meningitis  do  occasionally  make  a  recovery. 

Symptoms. — ^Ihe  symptoms  are  so  characteristic  that  little  difficulty 
is  experienced  in  recognizing  the  existence  of  meningitis.  Severe 
headache,  elevation  of  temperature  and  dulling  of  the  sensibilities, 
gradually  terminating  in  coma,  are  always  present.  Rigidity  of  the 
neck  is  usually  conspicuous  and  vomiting  irrespective  of  taking  food  is 
very  frequent.  A  positive  Kernig  is  perhaps  the  most  characteristic 
sATnptom,  especially  as  it  indicates  an  extension  to  the  spinal  canal  and 
is  not  found  in  other  intracranial  complications.  A  number  of  asso- 
ciated symptoms  sooner  or  later  appear,  such  as  optic  neuritis,  paral- 
ysis of  the  abducens,  as  well  as  of  other  cranial  nerves  and  finally  of 
the  extremities.  The  pulse  in  the  beginning  may  be  retarded,  but 
toward  the  end  is  rapid  and  irregular. 


COMPLICATIONS  OF  MASTOIDITIS  469 

Diagnosis. — ^It  is  only  in  the  beginning  that  one  may  experience 
any  difficulty  in  making  a  diagnosis  from  the  clinical  symptoms. 
In  doubtful  cases  the  lumbar  puncture  is  of  great  assistance.  When 
the  spinal  fluid  is  cloudy  and  contains  a  large  number  of  leukocytes,  or 
when  it  is  clear  but  under  considerable  pressure,  the  diagnosis  of  menin- 
gitis is  positive.  Further  than  this  one  is  not  justified  in  going.  The 
withdrawal  of  a  more  or  less  purulent  spinal  fluid  does  not  prove  that 
the  fluid  in  the  cranial  cavity  is  also  purulent,  since  the  increased 
leukocytes  in  the  spinal  fluid  may  be  in  the  nature  of  a  sediment  from  a 
diffuse  serous  meningitis,  and  xice  versa,  the  withdrawal  of  a  relatively 
clear  fluid  does  not  exclude  the  possibility  of  purulent  meningitis 
existing  in  the  cranium.  Even  when  the  spinal  fluid  is  found  to  be 
normal  one  cannot  be  certain  that  the  spinal  sac  may  not  be  shut  off 
from  the  cranial  cavity  by  a  fibrin  plug.  On  the  whole,  however,  a 
distinctly  purulent  fluid  withdrawn  by  the  spinal  puncture  means  a 
purulent  condition  of  the  meninges  within  the  cranium. 

Treatment. — In  view  of  the  facts  which  we  now  possess  regarding 
the  course  of  otitic  meningitis  the  treatment  for  these  cases  is  quite 
clear.  As  early  as  possible  the  focus  of  infection  in  the  mastoid  should 
be  eradicated,  the  dura  split  and  free  drainage  established.  Repeated 
spinal  puncture  to  relieve  the  ever-recurring  increased  pressure  is  to 
be  employed.  With  this  treatment  many  of  the  cases  of  serous  menin- 
gitis will  get  well,  and  occasionally  even  a  case  of  unquestionable  diffuse 
purulent  type  may  recover. 

Brain  Abscess  of  Otitic  Origin. — Abscess  of  the  brain  is  a  much  more 
frequent  complication  of  chronic  suppurative  otitis  media  than  of  the 
acute  disease.  It  develops  either  through  direct  extension  by  contact 
with  a  perforating  disease  of  the  mastoid  or  through  extension  of  infec- 
tion by  way  of  lymphatics  and  bloodvessel  connections  with  disease 
in  the  middle-ear  chambers  or  in  the  labyrinth.  The  location  of  such 
abscesses  is,  therefore,  as  a  rule,  more  or  less  definitely  determined. 
For  the  most  part  they  lie  in  the  middle  brain  fossa  just  over  the  middle- 
ear  chambers,  or  less  frequently  in  the  posterior  fossa  in  contact  with 
the  posterior  aspect  of  the  temporal  bone.  When  the  infection  extends 
through  the  roof  of  the  tympanum  or  mastoid  a  temporosphenoidal 
abscess  develops.  When  it  enters  the  posterior  fossa  a  cerebellar  abscess 
forms,  the  location  of  which  may  be  either  anterior,  that  is,  in  close 
relation  to  the  lateral  sinus,  which  is  more  frequent,  or  it  may  develop 
deep  in  the  cerebellum  where  this  structure  comes  in  contact  with  the 
posterior  aspect  of  the  petrous  bone  near  the  opening  of  the  internal 
meatus  or  the  aqueductus  vestibuli.  The  majority  of  brain  abscesses 
are  surrounded  by  a  distinct  capsule  and  are  filled  with  a  thick,  more  or 
less  odorless  pus.  A  smaller  percentage  lacks  the  capsule,  the  sur- 
rounding brain  substance  being  more  or  less  extensively  involved.  The 
pus  in  these  cases  is  usually  most  offensive. 

Symptoms. — In  order  to  keep  in  mind  the  multiform  symptoms  which 
accompany  brain  abscess,  it  is  convenient  to  consider  these  symptoms 
as  they  occur  during  the  several  stages  in  the  course  of  the  abscess. 


470  SUPPURATIVE  MIDDLE-EAR  DISEASE 

(1)  Is  the  "  initial  stage. "  Here  the  characteristic  symptoms  are  those 
of  meningeal  irritation  where  fever,  headache  and  vomiting  point 
clearly  to  a  circumscribed  infection  of  the  meninges.  (2)  Is  the  "latent 
stage. "  Here  the  complaint  is  from  headache  and  a  sense  of  pressure 
in  the  head.  The  pain  is  restricted  usually  to  the  same  side,  but  not 
necessarily  located  over  the  seat  of  the  abscess.  Not  infrequently  there 
is  sensitiveness  to  percussion  over  a  temporosphenoidal  abscess.  The 
patient  appears  ill,  has  no  appetite,  loses  weight,  is  mentally  depressed 
or  may  experience  exhiliration.  His  face  takes  on  a  grayish  color. 
There  may  be  attacks  of  vertigo  and  vomiting.  Seldom  is  there  any 
elevation  of  temperature.  (3)  Is  the  "manifest  stage,"  when  sjTiip- 
toms  of  intracranial  pressure  and  focal  symptoms  appear.  Common  to 
both  forms  of  brain  abscess  is  the  slowing  of  the  pulse,  and  optic 
neuritis.  These  are,  on  the  whole,  more  often  seen  in  cerebellar  abscess. 
The  focal  symptoms  depend  on  the  location  of  the  abscess.  A  peculiar 
form  of  sensory  aphasia,  "  word  blindness, "  where  the  patient  recognizes 
an  object  but  cannot  recall  the  name,  is  often  a  symptom  of  temporo- 
sphenoidal abscess  of  the  left  side  in  right-handed  individuals.  Nerve 
deafness  on  the  side  opposite  the  lesion  is  also  observed  in  cases  of 
cerebral  abscess  as  well  as  crossed  hemiparesis. 

Cerebellar  abscess  often  gives  rise  to  distinct  ataxic  symptoms,  with 
vertigo  and  nystagmus,  which  resemble  those  of  labyrinth  involvement. 
These  two  conditions  may  be  confused,  especially  because  a  suppurative 
labjTinthitis  often  precedes  the  development  of  a  cerebellar  abscess. 
The  differential  diagnosis  may  be  bafHing  unless  one  is  an  aurist  experi- 
enced in  diagnosing  labyrinth  disease.  The  following  points  may  be  of 
assistance  in  cases  in  which  a  suppuration  of  the  labyrinth  precedes 
the  development  of  symptoms  suggesting  cerebellar  abscess.  The 
infection  of  the  labyrinth  from  which  a  cerebellar  abscess  develops  is 
always  a  diffuse  labjTinthitis,  which  always  produces  a  total  destruc- 
tion of  the  hearing  as  well  as  the  function  of  the  semicircular  canals. 
The  vertigo  and  nystagmus  which  occur  as  the  result  of  the  sudden 
destruction  of  the  labyrinth  is  always  greatest  at  the  onset  of  the 
disease  and  diminishes  gradually,  disappearing  entirely  in  the  course 
of  a  few  weeks.  The  quick  movement  of  the  eyes  in  the  resulting 
nystagmus  is  toward  the  opposite  side.  When  an  intracranial  extension 
supervenes  as  the  result  of  an  extension  of  the  labyrinthitis  an  ever- 
increasing  vertigo  and  nystagmus  gradually  develops.  The  quick 
component  of  the  nystagmus  is  now^  usually  directed  toward  the 
affected  side. 

During  the  "manifest  stage"  of  brain  abscess,  symptoms  of  pressure 
causing  paralysis  of  various  cranial  nerves  develop.  The  fourth  or 
"terminal  stage"  is  marked  by  collapse,  as  the  result  of  a  rapidly 
spreading  meningitis  or  of  the  rupture  of  the  abscess  into  the  ventricle. 
As  a  matter  of  fact,  both  the  first  and  fourth  stages  are  quite  transitory, 
whereas  the  latent  stage  may  last  for  months  or  even  years  until  a 
sudden  unexpected  fatal  termination  supervenes. 

Treatment. — An  operation  for  the  location  and  relief  of  a  probable 
brain  abscess,  just  as  the  operation  for  any  of  the  intracranial  compli- 


COMPLICATIONS  OF  MASTOIDITIS  471 

cations  of  suppurative  otitis  media,  is  always  preceded  by  the  simple 
mastoid  exenteration  in  the  acute  cases,  and  the  radical  operation  in  the 
chronic  cases.  The  object  is  first  of  all  to  eradicate  the  source  of  the 
infection  in  the  middle  ear.  Another  reason  for  this  course  is  that  the 
location  of  the  abscess  is  most  readily  made  by  tracing  the  course  of 
the  infection  from  the  middle  ear.  When  one  finds  no  pathway  leading 
toward  the  brain  abscess  one  proceeds  cautiously  to  make  a  search 
either  in  the  middle-brain  fossa  or  in  the  posterior,  depending  upon 
whether  the  symptoms  point  more  toward  a  temporosphenoidal  or 
cerebellar  involvement.  When  one  suspects  an  abscess  in  the  middle 
fossa  the  whole  roof  of  the  middle-ear  chambers  is  removed  with  bone 
forceps  from  the  tympanic  orifice  of  the  Eustachian  tube  well  back 
toward  the  outer  angle  of  the  pyramid.  The  simple  mastoid  should  be 
made  into  the  radical  in  such  cases.  Should  a  careful  examination  of 
the  exposed  dura  disclose  no  alterations  pointing  to  the  course  of  the 
infection  the  next  step  is  to  puncture  the  dura  with  a  suitably  large 
aspirating  needle,  penetrating  the  brain  substance  upward  and  back- 
ward, not  over  four  centimeters.  In  case  an  abscess  is  located  by  this 
means  the  bone  is  freely  removed  over  the  abscess  by  means  of  bone 
forceps.  The  dura  is  freely  incised  and  a  suitable  drain  is  then  intro- 
duced, either  in  the  form  of  a  cigarette  drain  or  a  strip  of  gauze.  The 
failure  to  draw  pus  into  the  needle  does  not  exclude  the  possibility  of 
an  abscess.  When  the  symptoms  are  pressing  enough  the  exploration 
may  now  be  carried  farther  by  making  an  incision  in  the  dura,  to  be 
followed  by  three  or  four  punctures  with  a  knife. 

When  one  suspects  a  cerebellar  abscess  it  is  important  to  remember 
that  those  abscesses  which  follow  an  infection  of  the  labyrinth  are 
deeply  located  along  the  posterior  aspect  of  the  temporal  bone,  near 
the  orifice  of  the  internal  auditory  meatus.  The  abscess  in  such  cases 
is  reached  most  readily  by  chiselling  away  the  posterior  angle  of  the 
petrous  bone  just  in  front  of  the  lateral  sinus.  Injury  to  the  labyrinth 
is  of  no  consequence,  since  the  function  of  this  organ  has  already  been 
destroyed  in  the  course  of  the  labyrinthitis.  Aside  from  these  cases  of 
labyrinth  origin  all  other  cerebellar  abscesses  are  located  anteriorly, 
that  is,  in  more  or  less  close  proximity  to  the  lateral  sinus,  even  in  those 
cases  in  which  the  sinus  itself  has  not  been  infected.  These  abscesses 
are  reached  more  readily  by  making  an  opening  just  posterior  to  the 
knee  of  the  sinus.  In  either  case  the  sinus  itself  should  be  freely 
exposed. 

The  after-treatment  of  brain  abscess  requires  frequent  changing  of 
the  dressings  in  order  to  facilitate  adequate  drainage  for  the  profuse 
discharge.  It  is  especially  important  not  to  leave  out  the  drain  too 
early. 


SUEGERY  OF  THE  NOSE  AND  THEOAT. 


By  JOSEPH  C.  BECK,  M.D. 


THE  NOSE. 

In  discussing  the  surgical  management  of  the  nose,  we  will  consider 
the  subject  under  two  separate  heads,  namely: 

A.  The  exterior  of  the  nose. 

B.  The  interior  of  the  nose. 

The  exterior  component  is  made  up  of  a  bony  and  cartilaginous 
framework  and  covered  with  skin.  The  bones  are:  the  nasal  spine  of 
the  frontal  bone,  the  two  nasal  bones,  the  two  nasal  processes  of  the 
superior  maxilla,  and  the  rostrum  of  the  same  bone.  The  cartilages 
are  the  lateral  masses  joining  the  cartilaginous  portion  of  the  septum 
which  forms  the  tip  of  the  nose,  as  well  as  the  nostrils  (Fig.  188). 


■^"^^\\>x 


Fig.  188. — 1,  os  nasale;  2,  processus  iiasi  max.  sup.;  3,  cartilage  sesamoidea ;  4,  cartilage 
alaris  major;  5,  max.  sup.;  6,  spina  os  frontali;  7,  cartilage  nasi  lat.;  8,  cartilage  septi 
nasi;  9,  rostrum  os.  '  . 

The  interior  component  of  the  nose  is  also  made  up  of  bony  and 
cartilaginous  structures,  but  these  are  covered  by  mucous  membrane. 
The  bones  entering  into  the  formation  of  the  interior  component  are: 
the  ethmoid  with  its  superior  and  middle  turbinated  bodies  (Fig.  189) ; 
ethmoid  labjT-inth,  known   as  anterior  and  posterior  ethmoid  cells 

(473) 


474 


SURGERY  OF  THE  XOSE  AXD  THROAT 


(Fig.  190);  the  cribriform  plate  and  the  perpendicular  plate  (septum) 
(Fig.  191);     the  superior  maxilla  with  its  antrum  cavity  (Fig.  192); 


Fig.  189. — 1,  crista  galli;  2,  recessus  sphenoethmoidale;  3,  aperture  sinus  sphenoidales ; 
4,  sphenoid  sinus;  5,  concha  nasalis  suprenia;  6.  concha  nasalis  suprema:  7,  meatus  nasi 
sup.;  8,  ostium  pharj-ngeum  tubje;  9,  meatus  nasi  med.;  10,  os  palatina;  11,  concha 
nasalis  inf.;  12,  meatus  nasalis  inf.;  13,  frontal  sinus;  14,  agger  nasi;  1.5,  concha  nasalis 
med.;    16,  vestibulum;    17,  labium  sup. 


Fig.  190. — 1,  Left  sphenoid;  2,  right  sphenoid;  3,  post  etlunoid;  4.  infundib.;  5,  sinus 
frontalis;  6,  anterior  ethmoid;  7,  sup.  turbinated;  8,  sup.  meatus;  9,  mid.  turbinated; 
10,  mid.  meatus;   11,  irf.  turbinated;   12,  inf.  meatus. 


the  inferior  turbinated  body  (Fig.  189);  the  vomer  (Fig.  191)  and 
the  palate  bone  (Fig.  189).     Since  the  surgical  diseases  of  the  exterior 


THE  NOSE 


475 


component,  such  as  fractures,  abscesses,  tumors,  deformities  and  mal- 
formations, will  be  taken  up  in  other  chapters,  the   diseases  of  the 


Fig.  191. — 1,  lamina  cribrosa;  2,  lamina  perpendicularis;  3,  os  frontale;  4,  os  nasale;  5, 
cartilage  nasi  lat.;  6,  cartilage  septi  nasi;  7,  cartilage  alaris  major;  8,  processus  palatinus; 
9,  canalis  incisivnas;  10,  crista  nasalis  maxillse;  11,  sinus  sphenoidalis ;  12,  crista  sphenoid- 
alis;  13,  vomer;  14,  choana;  15,  spina  nasalis  post.;  16,  crista  nasalis  ossis  palatini. 


Fig.  192. — 1,  crista  galli;  2,  sinus  frontalis;  3,  cellula  ethmoidalis  ant. ;  4,  buUa  ethmoid- 
alis;  5,  processus  uncinatus;  6,  ostium  sinus  max.;  7,  concha  nasalis  med.;  8,  sinus  max.; 
9,  concha  nasalis  inf.;  10,  processus  palatini;  11,  septum  nasi;  12,  bulla  ethmoidalis;  13, 
ostium  sinus  max.;  14,  meatus  nasi,  med.;  15,  concha  nasalis  med.;  16,  concha  nasalis 
inf. ;  1 7,  meatus  nasi  inf. 

internal  component,  namely,  only  that  which  is  lined   with  mucous 
membrane  will  be  considered  here. 


476  SURGERY  OF  THE  NOSE  AND  THROAT 

In  order  to  be  able  to  make  a  correct  diagnosis,  and  to  administer 
proper  treatment,  it  is  essential  for  the  surgeon  to  see  clearly  within 
this  dark  area  (the  nasal  cavity).  This  is  only  possible  by  a  thorough 
training  with  the  use  of  the  reflected  light.  Practically  no  operative 
procedure  can  be  performed  without  the  use  of  good  illumination. 

The  principal  pathologic  conditions  met  with  in  the  interior  com- 
ponent of  the  nose  are : 

1.  Obstructions. 

2.  Infections. 

1.  Septum. — Obstruction  is  most  frequently  caused  by  a  deflection 
of  the  septum,  hov.'ever  there  is  usually  some  concomitant  hyper- 
trophy of  the  middle  and  inferior  turbinated  bodies.  The  deviation 
of  the  septum  is  usually  in  the  anterior  or  cartilaginous  portion,  but 
the  bony  portion  has  some  deflections  wdth  excrescences  called  ridges 
and  spurs.  These  are  formed  along  the  junction  of  the  bony  and 
cartilaginous  portion  of  the  septum,  as  well  as  the  union  between  the 
vomer,  perpendicular  ethmoid  and  superior  maxilla  (floor  of  the  nose, 
known  as  maxillary  ridge) .  A  very  important  anatomical  and  surgical 
point  is  the  periosteum  and  perichondrium  which  traverses  the  septum 
anteriorly  as  it  comes  over  from  the  floor  of  the  nose.  There  are  at 
times  septa  deflections  that  protrude  from  one  side  or  the  other  of  the 
nose,  carrying  with  it  the  tip  and  giving  the  nose  a  crooked  appearance. 
Aside  from  causing  obstruction  to  breathing  the  deflections  give  rise 
to  difBculty  in  ventilating  the  nasal  accessory  sinuses  and  middle 
ear,  predisposing  to  infection  and  deafness.  Another  complaint  often 
expressed  is  pain  due  to  the  pressure  of  the  septum  laterally  against 
the  sensitive  structures.  These  pains  may  be  referred  and  neuralgic 
in  character  as  is  a  toothache. 

Treatment. — Aside  from  temporary  relief  by  shrinking  with  adrenalin 
and  other  astringents,  there  is  but  one  rational  thing  to  do  and  that  is 
to  operate.  Before  the  classical  submucous  resection  of  the  nasal 
septum  was  devised  about  fifteen  years  ago,  there  was  a  great  multi- 
plicity of  operative  procedures  from  a  resection  of  a  ridge  or  spur,  to 
an  Ash  operation;  but  today  only  the  submucous  resection  is  accept- 
able. 

Technic. — Patient  is  placed  in  a  semi-recumbent  position,  a  cotton 
applicator  is  soaked  in  adrenalin  solution  one  to  one  thousand,  and 
this  is  subsequently  dipped  into  the  flaked  cocaine  (commercial  pro- 
duct). By  means  of  this  mixture  both  sides  of  the  septum  are  gently 
swabbed.  About  10  grains  of  the  flakes  of  cocaine  is  consumed  in  the 
average  case,  and  it  requires  about  fifteen  minutes  before  the  patient 
is  ready  for  operation. 

Steps  oi  Operation. — 1.  Introduction  of  the  Heft'ernan  self-retaining 
nasal  speculum  (Fig.  193)  on  the  convex  side  of  the  deflection. 

2.  Incision  anterior  to  the  greatest  prominence  of  the  deflection, 
down  to  the  cartilage.  This  incision  should  be  carried  well  down  to  the 
floor  of  the  nose  (Fig.  194). 

3.  By  means  of  the  same  knife  (Fig.  195)  the  mucoperichondrium 


THE  NOSE 


477 


is  elevated  for  a  slight  distance  with  the  greatest  care,  in  order  not  to 
shred  it,  until  one  reaches  the  much  looser  attachment  further  back. 


Fig.  193.- — Heffernan  nasal  speculum. 

4.  By  means  of  a  semi-blunt  elevator  (Fig.  196)  the  entire  cartilage 
as  well  as  the  bone,  is  separated  from  the  mucoperiosteum  and  peri- 
chondrium (Fig.  197). 


Fig.  194. 


5.  At  the  anterior  portion  of  the  septum,  near  the  floor  of  the  nose, 
where,  as  mentioned  before,  the  perichondrium  passes  through  the 
cartilage,  it  is  necessary  to  employ  the  knife  to  free  this  attachment 
before  one  can  dissect   the   mucoperichondrium   down   to  the  floor. 


Fig.  195.^Freer's  septum  knife. 

This  portion  of  the  technic  is  very  difficult  and  may  result  in  a  tear 
especially  when  there  previously  existed  an  ulceration  at  that  point 
(Fig.  198). 

6.  By  means  of  the  knife  the  cartilage  is  cut  obliquely  at  the  same 
point,  as  the  original  incision  of  the  mucoperichondrium.     Great  care 


478 


SURGERY  OF  THE  NOSE  AND  THROAT 


must  be  exer.cised  not  to  cut  through  the  mucoperichondrium  on  the 
opposite  side. 


"^•'^jfadnatttaMMBBteM 


l^e^= 


Fig.  196. — Hajek-Ballinger  elevator. 


Fig.  197. 


Fig.  198. —  1,  perichondrium  passing  through  septum. 


^^^^^?^^[^jBBB!H 


Fig.  199. — Freer's  elevator. 


7.  Insertion  of  the  second  Heffernan  speculum   into  the  opposite 
nostril. 


THE  XOSE 


479 


8.  By  means  of  the  fine  blunt  dissector  (Fig.  199)  the  opposite 
mucoperichondrium  is  separated  from  the  cartilage  and  bone,  the 
same  as  on  the  convex  side. 

9.  The  same  procedm-e  of  severing  the  perichondriimi  as  it  passes 
through  the  anterior  portion  of  the  septiun,  is  employed,  thus  having 
freed  both  sides  of  the  septiun  through  a  single  incision. 


Fig.  200. — Killian's  nasal  speculum. 


Fig.  201. 


Fig.  202. — Ballenger's  swivel  knife. 


10.  Insertion  of  a  thin-bladed  bivalve  speculum  (Fig.  200)  into  the 
incision,  each  blade  on  either  side  of  the  cartilage  (Fig.  201). 


480 


SURGERY  OF  THE  XOSE  AXD  THROAT 


11.  Slight  opening  of  this  speculum  exposes  the  cut  surface  of  the 
septum.  By  means  of  the  Ballenger  swivel  kAife  (Fig.  202)  the  blade 
of  which  straddles  the  cartilage  at  the  upper  section,  remove  a  section 
of  the  cartilage  (Fig.  203).  The  first  sweep  of  the  knife  is  made  up  and 
backward  by  a  pushing  motion  until  the  bone  is  encountered.  Care 
must  be  exercised  not  to  pass  the  swivel  knife  too  close  to  the  bridge 
of  the  nose,  thus  weakening  the  support  which  may  result  in  a  saddle 
nose,  especially^in  case  of  infection  or  trauma. 


Fig.  203. 

The  next  sweep  of  the  knife  is  downward,  and  continuing  forward, 
when  the  section  of  the  cartilage  will  have  been  completed. 

12.  By  means  of  a  good  grasping  forceps  (Fingers,  Fig.  220)  the  edge 
of  the  cut  cartilage  is  grasped  and  "withdrawn  even  though  it  may  be 
much  larger  than  the  incision  in  the  mucoperichondriiun. 

13.  The  removal  of  the  ridge  which  is  very  frequently  present  near 
the  floor  of  the  nose  is  best  accomplished  by  a  gouge  (right  and  left, 
Fig.  204)  which  is  guarded  against  the  possible  tearing  of  the  muco- 
perichondrium  flap  (Fig.  205). 


Fig.  204.— Black's  chisel. 


14.  Bony  deflections  are  best  removed  by  means  of  a  forceps  (Fig. 
206,  Luc-Br tinning)  which  grasps  the  septum  on  either  side  (Fig.  207) 
and  by  a  slow  twisting  motion  is  broken.  This  forceps  removes  only 
the  bone  within  the  grasp  of  its  blades  and  therefore  is  a  safeguard 
against  possible  linear  fractures  beyond  the  point  intended. 

15.  After  bringing  the  flaps  in  apposition,  both  sides  of  the  nose  are 
to  be  packed.  In  case  of  the  incision  having  been  made  in  the  muco- 
cutaneous junction,  it  is  best  to  unite  it  by  a  single  stitch  (Fig.  208), 
thus  aiding  in  more  rapid  healing,  with  less  crust  formation. 


THE  NOSE 


481 


16.  Packing  of  the  nose  may  be  done  by  splints  made  of  compressed 
cotton,  originally  used  by  Bernay.  These  splints  are  of  different 
lengths  (Figs.  209  and  210).    While  introducing  the  splint  or  packing, 


Fig.  205. — 1,  ridge;  2,  chisel. 


Fig.  200. — Luc-Briinning's  septum  forceps. 


Fig.  207. 


Fig.  208, 


one  should  cover  the  incision  with  the  blade  of  the  nasal  speculum. 
Instead  of  the  splints  one  may  use  gauze  strips  covered  with  vaselin. 
The  packing  should  be  systematically  placed  into  the  nose,  layer  for 
layer  from  below  upward  and  firmly  pack  both  sides,  thus  preventing 


VOL.  I — 31 


482 


SURGERY  OF  THE  NOSE  AND  THROAT 


the  possibility  of  a  hematoma.  A  small  strip  of  adhesive  plaster  is 
passed  across  the  nostrils  preventing  the  expulsion  of  the  packing  in 
case  of  sneezing  (Fig.  211). 

After-treatment. — Remove  packing  next  da}'. 


Fig.  209. — Bernay's  splint. 


Fig.  210. 


■~=^^Vsvstv^ 


.^^^^^i-i'^y.. 


Fig.  211. 


Complications. — These  occur  very  seldom.  One  of  the  most  common 
complications  is  a  "hematoma"  between  the  mucoperichondrium  and 
periosteal  flaps.  This  always  causes  an  obstruction  to  breathing. 
The  cause  is  that  the  packing  in  the  nose  was  too  loose,  or  that  it 
was  removed  too  soon.  At  tunes  this  hematoma  becomes  infected, 
adding  pain  and  temperature  to  the  sj-mptoms.    In  such  cases  it  is 


THE  NOSE  483 

best  to  open  the  original  incision,  remove  infected  blood  clot,  mop  out 
with  iodin  and  pack  gauze  between  the  mucoperichondrial  flaps  for 
twenty-four  hours.  After  removing  the  gauze,  the  flaps  are  again 
approximated  and  the  nose  is  packed  as  after  operation  for  twenty-four 
to  forty-eight  hours. 

Occasionally  in  spite  of  proper  packing  a  continuous  "oozing"  or 
even  hemorrhage  may  take  place.  This  is  either  due  to  a  blood  dyscra- 
sia  or  there  may  have  been  an  injury  to  the  anterior  palatine  artery, 
while  removing  the  ridge  at  the  floor  and  not  packed  sufficiently  tight 
at  that  point. 

Secondary  infection  of  the  nasal  accessory  sinuses,  middle  ear  and 
tonsillitis  also  occur,  especially  if  the  packing  is  allowed  to  remain 
longer  than  twenty-four  hours  or  if  possibly,  the  septum  operation  was 
performed  while  there  was  an  acute  inflammation  about  the  nasal  or 
pharyngeal  cavities,-  The  management  of  these  complications  is  referred 
to  elsewhere. 

Local  and  general  sepsis  in  the  form  of  a  meningitis,  septic  sinus 
thrombosis  (great  longitudinal)  has  been  reported  following  septum 
resections. 

Flapping  of  the  resected  septum  due  to  excessive  removal,  especially 
of  the  bony  portion,  is  at  times  met  with.  It  is  very  annoying  especially 
when  the  patient  attempts  to  expire  the  air  forcibly  through  the  nose, 
which  causes  an  obstruction.  To  remedy  this  difficulty  is  either  to 
reopen  the  mucoperichondrial  and  periosteal  flaps  and  insert  a  piece 
of  cartilage  of  a  resected  septum  of  another  patient,  or  make  a  linear 
perforation  through  the  septum  near  the  floor  of  the  nose  somewhat 
back.  This  is  best  done  by  an  electric  cautery  and  subsequently  kept 
open,  by  inserting  a  probe  through  the  incision  daily  for  about  one 
week. 

11.  Inferior  Turbinated  Body. — Obstructions  to  breathing,  venti- 
lation and  drainage  of  the  nasal  accessory  sinuses  and  ears,  are  the 
most  frequent  difficulties  encountered,  when  this  structure  is  patho- 
logically changed.  The  various  pathological  changes  that  the  writer  has 
investigated,  especially  by  histological  examination  are:  Turgescence 
(Fig.  212),  papillary  hypertrophy  ((Fig.  213),  epithelial  hypertrophv 
(Fig.  213),  atrophy  (Fig.  214). 

There  are  other  pathologic  changes  both  acute  and  chronic  which, 
however,  seldom  if  ever  call  for  surgical  intervention.  These  are  the 
acute  inflammations,  the  chronic  engorgement  associated  with  renal 
and  cardiac  diseases,  the  ischemic  or  boggy  type  usually  present  in 
the  hyperesthetic  form  of  rhinitis  and  the  rapid  alternating  dilatation 
and  contraction  as  found  in  certain  vasomotor  conditions.  Excluding 
these  later  forms  and  the  atrophic  inferior  turbinate,  the  operative 
interference  does  not  differ  much  in  the  first  three  forms  mentioned. 
One  of  the  principle  facts  in  reference  to  the  inferior  turbinate  bodies 
which  is  to  be  remembered,  is  to  be  extremely,  let  me  repeat  it,  extremely 
conservative  in  the  removal  or  destruction  of  any  part  of  them.  Per- 
haps no  other  structure  within  the  nose  has  been  more  abused  by  the 


484 


SURGERY  OF  THE  NOSE  AND  THROAT 


general  surgeon  and  specialists,  than  the  inferior  turbinate,  with  very 
annoying  and  lasting  after-effects  of  dryness  both  of  the  nose  as  well 
as  of  the  throat. 


Fig.  212. — Chronic  intumescence  of  the  inferior  turbinate  body.  Marked  inflam- 
mation of  the  surface  epithelium.  New  bloodvessels.  Almost  complete  atrophy  of 
all  the  glands. 


Fig.  213. — Very  marked  thickening  of  the  epithelium  of  the  papilla. 


Treatment. — Three  principal  methods  are  employed  usually  in  the 
order  mentioned : 

1.  Actual  galvanic  cautery. 


TUB  NOSE 


485 


2.  Crushing. 

3.  Limited  removal. 

Actual  Cautery. — A  good  transformer,  cords,  handle  and  points 
are  required  to  do  good  work  (Fig.  215). 


Fig.  214. — Inferior  turbinate  in  atrophic  rhinitis  (chip  removed  experimentally). 
Showing  metaplasia  of  epithelium  of  the  median  side  and  thickening  of  the  antral  side. 
Mucous  glands  are  still  present,  although  distended. 


Fig.  215. — Galvanocautery. 

Local  anesthetic,  flaked  cocaine  limited  to  the  surface  of  inferior 
turbinate. 

Operation. — Heat  the  cautery  point  to  slightly  more  than  the  red 
heat. 

1.  Introduce  the  electrode  cold  and  apply  to  the  most  posterior 
portion  of  the  turbinate  and  at  the  junction  of  the  lower  one-third 


486 


SURGERY  OF  THE  NOSE  AND  THROAT 


with  the  upper  two-thirds  (Fig.  216)  and  then  heat  by  making  contact 
of  trigger  of  handle. 

2.  A  slow  short  see-saw  movement  burrowing  the  electrode  until 
the  bone  is  felt. 

3.  Continue  the  same  procedure  on  a  line  forward,  until  the  most 
anterior  portion  of  the  turbinate  is  reached,  when  the  electrode  is 
withdrawn  still  hot.  Care  must  be  taken  in  withdrawing  the  heated 
point,  not  to  touch  any  part  of  the  vestibule  of  the  nose. 

4.  Fill  the  entire  nasal  cavity  with  white  vaselin  from  a  collapsible 
■tube. 

After-treatment. — Have  the  patient  repeat  this  introduction  of 
vaselin  every  two  or  three  hours.  The  nose  should  be  examined  for 
several  days  after  and  the  turbinated  body  kept  separated  from  the 
septum,  thus  preventing  the  formation  of  a  synechia. 


Fig.  216. — -1,  faulty  technic;  2,  location  of  actual  cautery  line  (correct). 


Crushixg. — This  procedure  is  a  makeshift  between  the  galvanic 
cautery  and  resection. 

Technic  of  Operation. — The  writer's  instrument  (Fig.  217)  known  as 
a  conchotribe  is  inserted  in  such  a  manner  as  to  cause  the  blades  to 
encircle  the  lower  or  free  border  of  the  inferior  turbinated  body  (Fig. 
218)  closing  the  blades  completely  and  immediately  releasing  will 
result  in  the  proper  shrinkage  when  healing  has  taken  place.  This 
crushing  is  started  anteriorly  and  continued  backward  until  the  entire 
length  of  the  lower  border  of  the  inferior  turbinated  body  has  been 
crushed.  When  the  posterior  portion  is  reached,  one  will  frequently 
find  a  much  greater  hypertrophy  which  really  causes  the  greater  amount 
of  trouble,  especially  affecting  the  mouth  of  the  Eustachian  tube.  In 
that  case,  the  crushing  blades  of  the  conchotribe  should  be  allow^ed  to 
remain  closed  for  two  or  three  minutes,  thus  obtaining  better  and  more 
lasting  results. 

There  is  seldom  any  bleeding  following  this  procedure,  but  if  it 


¥he  nosS 


48? 


occurs  then  a  long  Bernay's  splint  (Fig.  209),  placed  in  the  inferior 
meatus,  will  control  the  same.  This  should  be  removed  the  next  day 
and  the  after-treatment  is  the  same  as  after  the  cautery. 


Fig.  217. — Beck's  concho tribe. 


Resection.- — As  stated  in  the  beginning  only  partial  resection  of 
the  inferior  turbinate  is  permissible  in  good  rhinological  surgery  and  it 
is  confined  to  the  lower  or  overgrown  margins  and  particularly  to  its 


Fig.  218. 


posterior  portion.  This  at  times  takes  on  the  appearance  of  a  tumor 
with  pedicle  and  after  removal  or  by  the  aid  of  a  postrhinoscopic 
mirror  will  appear  studded  like  a  mulberry  and  therefore  carries  that 
name,  mulberry  hypertrophy. 


488 


SURGERY  OF  THE  NOSE  AND  THROAT 


Teclmic  of  Operation. — 1.  By  means  of  the  cutting  instrument, 
author's  conchotome,  the  lower  edge,  including  a  thin  portion  of  the 
bone,  is  cut  from  forward  back,  until  the  posterior  enlargement  is 
reached  (Fig.  219). 


Fig.  219. 


2.  Grasp  this  posterior  enlargement  with  a  threaded  Michel  clip. 
(This  is  applied  by  a  small  alligator  forceps,  described  in  the  septum 
operation  as  Fingers,  Fig.  220.) 


Fig.  220.— Michel  clip  threaded. 

3.  Pass  a  snare  about  the  already  resected  lower  border  and  the 
thread  of  the  Michel  clip  as  far  back  as  the  posterior  end.  By  slight 
traction  on  the  above-mentioned  thread  of  the  clip  (Fig.  221)  the 
posterior  end  is  easily  encircled.  Drawing  the  snare  wire  down  will 
remove  the  entire  resected  mass  which  is  withdrawn  by  the  threaded 
Michel  clip. 

Bleeding  is  at  times  very  free,  especially  from  the  posterior  end, 
consequently  always  employ  the  conchotribe  after  resection. 


THE  NOSE 


489 


4.  The  concliotribe  is  applied  as  was  described  in  the  technic  of 
crushing  (Fig.  218). 

5.  A  long  Bernay's  splint  is  inserted  for  twelve  hours. 


Fig.  221. 

Nasal  Accessory  Sinuses. — In  the  study  of  the  surgery  of  these 
sinuses,  it  is  necessary  to  consider  them  both  from  the  intranasal  and 
external  routes. 

The  nasal  accessory  sinuses  are  anatomically  divided  into  (a)  anterior 
group  and  (&)  posterior  group. 

The  anterior  group  comprises  the  frontal  sinus,  anterior  ethmoid 
cells  and  antrum  of  Highmore;  the  posterior  group  is  composed  of 
the  posterior  ethmoid  cells  and  sphenoid  sinus.  Surgically,  the  anterior 
and  posterior  etlmioidal  cells  as  well  as  the  sphenoid  sinus  are  attacked 
intranasally,  whereas  the  frontal  sinus  and  antrum  of  Highmore  may 
be  operated  upon  intranasally  as  well  as  by  external  methods.  The 
indications  for  nasal  accessory  sinus  operations  are  principally  to  estab- 
lish ventilation  and  drainage  thus  relieving  the  sjTnptoms  of  irritation, 
pain  and  infection.  The  presence  of  pus  is  one  of  the  cardinal  sjrmp- 
toms;  however,  there  are  more  cases  of  so-called  non-suppurative 
inflammation  of  the  nasal  accessory  sinuses  calling  for  operative 
interference,  than  those  in  which  pus  is  demonstrable.  These  so- 
called  non-suppurative  cases  are  in  reality  degenerative  changes  in 
the  bones  and  mucosa;  however,  secondary  latent  infection  and  reten- 
tion, especially  in  the  ethmoid  lab^Tinth  is  acknowledged.  Since  the 
advent  of  the  belief  of  chronic  focal  infection,  these  sinuses  have 
assumed  greater  importance  as  the  seat  of  the  trouble  and  the  drainage 
and  ventilation  of  the  same  have  given  some  striking  results.  The  close 
anatomical  relation  between  the  vital  structures,  as  the  brain  and  eyes, 
is  an  additional  reason  for  recognizing  pathological  processes  of  the 
nasal  accessory  sinuses.  In  the  study  of  the  pathology  of  the  various 
types  of  nasal  accessory  sinus  disease,  the  writer  has  demonstrated, 
especially  histologically,  the  following  types  of  changes  which  can  in 
the  majority  of  instances  be  verified  by  a  good  stereoroentgenogram : 


490  SURGERY  OF  THE  NOSE  AND  THROAf 

1.  Chronic  suppurative  inflammation  of  the  mucosa. 

2.  Involvement  of  the  bone  such  as  osteitis  and  necrosis  with 
granulation. 

3.  Acute  inflammatory  changes  engrafted  upon  chronic  osteitis, 
necrosis  and  granulations. 

4.  Non-suppurative  changes  as  mA.'xomatous  degeneration  of  mucosa. 

5.  IMj-xomatous  changes  of  the  mucous  membrane  with  the  forma- 
tion of  true  polypi. 

6.  ^M^-xomatous  changes  of  the  mucous  membrane  with  osseous 
rarefaction. 

7.  jNIarked  atrophic  changes  of  mucosa  with  increase  of  connective 
tissue,  probably  many  are  luetic;  in  these,  there  are  evidences  of  bony 
rarefaction  and  necrosis. 

8.  Neoplasms  other  than  mucous  membrane  pol\T)i. 

In  the  diagnoses  of  sinus  disease  probably  no  finding  is  as  valuable, 
as  stated  before,  as  the  roentgenographic,  especially  if  a  stereoscopic 
picture  is  made.  It  is  very  important  to  determine  the  clinical  diag- 
nosis from  inspection  of  the  nose,  the  history,  etc.,  in  order  to  interpret 
properly  the  picture,  in  the  ^Titer's  opinion  based  upon  considerable 
experience.  Only  the  clinician  should  interpret  the  roentgenogram 
and  use  it  for  diagnostic  purposes.  It  stands  to  reason  that  if  he 
has  been  properly  trained  in  this  work  he  is  in  a  better  position  to 
do  this  than  the  ordinary  roentgenologist.  It  is  quite  difficult  to 
obtain  satisfactory  roentgenograms  of  the  sinuses  of  a  uniform  technic, 
owing  to  the  lack  of  information  on  the  part  of  the  average  roent- 
genologist. They  make  good  chest,  abdominal,  kidney  and  bone  pic- 
tures, but  when  it  comes  to  the  sinuses  and  mastoids  or  any  other 
part  of  the  skull,  they  are  far  less  competent.  The  sjinptom  of 
localized  pain  must  not  be  looked  for  too  closely,  because  an  affection 
of  the  sphenoid  may  cause  the  pain  to  be  referred  to  the  frontal  or 
vertex  region,  or  an  antrum  of  Highmore  affection  may  cause  a  frontal 
or  temporosphenoidal  pain.  Tenderness  on  light  percussion  or  pressure 
over  the  forehead,  across  the  nose  and  inner  surface  of  orbit  and  over 
the  anterior  surface  of  the  superior  maxilla,  will  suggest  the  possibility 
of  a  frontal,  ethmoidal  and  antral  inflammation,  although  this  s\Tnptom 
refers  particularly  to  acute  cases  or  acute  exacerbation  of  chronic  diseases. 

The  periodicity  of  the  pain  and  headache  usually'  in  the  early  hours 
of  the  day,  is  of  considerable  value,  especially  in  more  acute  cases. 
Symptoms  referable  to  the  eyes,  especially  loss  of  vision,  congestion 
of  the  conjunctivae,  disturbance  of  balance  of  the  extrinsic  muscles 
with  small  errors  of  refraction  not  well  corrected  by  lenses,  are  some 
of  the  very  common  findings  of  sinus  disease.  Nasal  obstruction  is 
very  commonly  complained  of,  especially  when  the  middle  turbinated 
body  is  much  degenerated  or  inflamed  and  especially  when  there  are 
poh-pi  present.  ^Mienever  these  are  present  it  means  sinus  disease, 
usually  ethmoidal  and  only  when  these  cells  are  thoroughly  removed, 
can  one  hope  to  eradicate  these  gro^\i:hs  and  even  then  reciu'rences  are 
not  at  all  uncommon. 


fH^  NOSE  401 

The  constant  presence  of  pus  either  in  the  middle  or  superior  meatus 
is  almost  certain  to  indicate  sinus  disease. 

Dizziness  is  a  very  common  symptom  and  especially  elicited  on 
stooping  or  walking  up  and  down  stairs. 

In  the  non-suppurative  form  more  than  in  the  cases  where  pus  is 
present,  will  the  patients  complain  of  loss  of  the  sense  of  smell,  or  an 
abnormal  sense  of  smell,  owing  to  the  affection  of  the  olfactory  nerves. 

Very  frequently,  in  the  non-suppurative  form  there  is  irritation  of 
the  sensory  nerves,  causing  a  great  deal  of  sneezing,  followed  by  marked 
discharges  of  a  watery  secretion. 

Secondary  involvements  either  by  direct  continuity  of  structures  or 
by  nervous  reflexes  implicate  the  pharynx,  Eustachian  tubes  and  ears, 
larynx,  trachea,  bronchi  and  even  the  lungs,  giving  rise  to  symptoms 
from  these  structures.  In  sphenoidal  disease,  particularly  do  we  see 
frequent  pharyngo-laryngo-trachitis  developing,  causing  the  patient 
to  cough;  bronchitis  and  asthma  are  well  recognized  as  being  associated 
with  nasal  accessory  sinuse  disease  especially  the  non-suppurative 
type  and  attention  to  these  will  bring  about  great  amelioration  of 
symptoms  both  in  bronchitis  and  asthma.  Of  recent  years  the  pediat- 
rician recognizes  the  condition  of  sinusitis  in  children  and  the  causative 
influence  it  may  have  on  their  so-called  colds  with  bronchitis.  Equally 
good  results  are  obtained  in  this  later  condition  when  these  diseased 
sinuses  in  children  receive  proper  attention. 

Transillumination  is  of  particular  value  in  diseases  of  the  antrum 
of  Highmore,  although  in  some  large  frontal  sinuses  in  which  the 
anterior  wall  is  anatomically  not  too  thick,  it  will  show  a  shadow  in 
case  of  disease. 

Examination  of  teeth,  especially  by  the  aid  of  a  roentgenographic 
film,  will  aid  in  establishing  a  diagnosis  of  an  antrum  infection  from  this 
source  in  many  instances. 

Puncture  of  the  antrum  by  a  trocar  needle  and  washing  out,  will  at 
times  demonstrate  pus  when  no  other  objective  finding  is  present.^ 

Treatment. — In  the  suppurative  form  of  sinus  disease  only  can  one 
expect  any  results  from  non-surgical  treatment,  but  let  it  be  well 
borne  in  mind  that  chronic  sinus  disease  has,  as  a  rule,  so  changed  the 
tissues  that  operative  interference  is  the  only  measure  to  relatively 
cure  a  patient.  I  say  relatively,  because  when  once  a  sinus  is  chroni- 
cally affected  only  the  most  radical  procedure  can  bring  about  a  cure, 
and  that  is  principally  confined  to  the  frontal  sinus  and  antrum  of 
Highmore. 

The  majority  of  acute  sinus  diseases,  especially  if  not  engrafted 
upon  previous  chronic  diseased  conditions,  will  recover  through 
simply  assisting  drainage  and  ventilation  by  topical  applications  of 
adrenalin,  1  to  1000,  and  cocain,  2  per  cent.,  to  either  side  of  the  middle 
turbinated  body.  As  soon  as  the  very  acute  symptoms  have  sub- 
sided, then  the  use  of  irrigation  under  direct  inspection  by  means  of 

1  The  enumeration  of  the  signs  and  symptoms  above  are  arranged  in  their  importance 
and  frequency  and  not  systematically  as  objective  or  subjective. 


492 


SURGERY  OF  THE  NOSE  AND  THROAT 


Beck's  wash  bottle  apparatus  (Fig.  222)  is  indicated.  Normal  salt 
solution  is  employed  in  the  vicinity  of  the  openings  to  the  sinuses, 
that  is  under  the  middle  turbinate  anteriorly  and  between  it  and  the 
septum  further  back,  will  aid  in  the  resolution  of  the  process.     The 


Fig.  222. — Beck's  wash-bottle. 


use  of  gentle  suction  by  the  aid  of  Beck's  suction  apparatus  (Fig.  223), 
following  the  instillation  of  adrenalin  solution,  1  to  5000,  by  the 
writer's  method  will  give  further  relief.  This  line  of  treatment  can  be 
further  amplified  by  the  use  of  silvol,  5  per  cent,  solution,  in  the  same 


Fig.  223. — Beck's  suction  apparatus. 


manner  as  described  in  the  use  of  the  adrenalin  solution.  These 
treatments,  namely,  adrenalin,  suction  and  silvol,  should  be  carried 
out  three  or  four  times  a  day  at  home  until  symptoms  have  subsided, 
when  the  treatment  is  gradually  discontinued.     In  case  of  severe  pain 


THE  NOSE  493 

over  the  region  of  the  antrum,  with  definite  symptoms  of  involvement 
of  that  sinus,  it  may  become  necessary  to  puncture  the  sinus  through 
the  nose  in  the  inferior  meatus.  However,  it  should  be  borne  in  mind 
to  do  as  little  surgically  within  the  nose  during  an  acute  process  as  pos- 
sible, owing  to  the  great  danger  of  secondary  infection  of  the  meninges. 
All  kinds  of  soundings  and  probing  of  the  sinuses  should  be  avoided 
for  the  same  reason.  The  writer  has  seen  several  cases  of  local  or 
general  meningitis,  in  consultation,  following  just  such  irrational  and 
dangerous  treatment.  (The  technic  of  antral  puncture  will  be  des- 
cribed later.)  During  the  acute  suppurative  process  it  is  well  to 
determine  the  bacteriological  findings  and  preserve  a  culture  to  the 
extent  of  subculturing,  and  if  the  patient  does  not  make  an  uneventful 
recovery,  say  within  three  weeks'  time,  then  have  an  autogenous 
vaccine  made  and  employed  according  to  the  accepted  method  of 
vaccine  therapy.  In  the  treatment  of  chronic  suppurative  sinuses, 
and  we  may  say  that  with  the  exception  of  the  antrum  infection  of 
dental  origin,  all  of  the  sinuses  on  one  side  are  usually  involved  at  the 
same  time.  At  any  rate  the  anterior  group,  that  is,  the  frontal,  anterior 
ethmoid  cells  and  antrum,  are,  and  later  the  posterior  group,  that  is 
the  posterior  ethmoid  cells  and  sphenoid  sinuses.  The  writer  has  for 
years  followed  about  the  same  surgical  procedures  in  sequence  as  will 
be  described,  unless  there  were  some  special  reasons  to  deviate  from 
them. 

1.  Removal  of  middle  turbinated  body,  breaking  down  and  curetting 
both  the  anterior  and  posterior  ethmoidal  cells,  passing  sounds  into 
the  frontal,  antrum  and  sphenoid  sinuses  through  their  natural  open- 
ings without  attacking  any  part  of  the  sinus  itself. 

2.  If  following  this  procedure  and  adequate  after-treatment  the 
symptoms  still  persist  or  progress,  then  the  openings  of  the  channels 
leading  to  these  sinuses  are  enlarged  as,  for  instance,  taking  off  part  of 
the  wall  of  the  nasofrontal  duct,  nasal  wall  of  the  antrum  at  the  middle 
meatus  or  anterior  and  anterolateral  wall  of  the  sphenoid  sinus.  In 
case  that  one  or  all  of  the  sinuses  still  continue  either  to  suppurate  or 
are  blocked  by  pathological  tissues,  then  more  radical  measures  become 
necessary,  as  will  be  described  in  the  technic. 

Technic. — Middle  turbinectomy,  ethmoidal  exenteration  and  sinus 
exploration. 

Local  Anesthesia. — Patient  placed  in  a  semirecumbent  position,  as 
in  the  septum  operation.  The  same  technic  of  cocainization,  except 
that  the  application  is  made  directly  under  and  above  the  middle 
turbinated  body. 

Steps  of  Operation. — 1.  By  means  of  Finger  forceps  (Fig.  220)  the 
threaded  Michel  clip  is  applied  to  the  anterior  extremity  of  the  middle 
turbinated  body  (Fig.  224). 

2.  The  attachment  of  the  middle  turbinated  body  to  the  lateral 
ethmoid  mass  is  severed  from  before  backward  by  means  of  the  writer's 
conchotome  as  far  as  two-thirds  of  its  extent  (Fig.  224). 

3.  Without  removing  the  instrument,  when  this  cut  has  been  com- 


494 


SURGERY  OF  THE  NOSE  AND  THROAT 


pleted,  the  remains  of  the  attachment  of  the  middle  turbinate  are  broken 
off  by  bearing  down  on  the  conchotome.  This  procedure  will  cause  the 
middle  turbinated  to  be  dislodged  into  the  inferior  meatus,  hanging 
on  by  the  remains  of  its  membranous  attachment. 


Fig.  224. 


4.  The  thread  of  the  ]Michel  clip  is  passed  through  the  Krause 
nasal  snare  (Fig.  225),  which  in  turn  is  passed  about  the  severed  middle 
tm-binal.  This  maneuver  is  facilitated  by  slight  traction  on  the  thread 
while  an  assistant  is  holding  the  nostril  open  by  a  medium  long  nasal 


Fig.  225. — Krause's  nasal  snare. 


speculum  (Fig.  200).  Drawing  down  the  wire  will  sever  this  mem- 
branous attachment,  and  by  the  aid  of  the  thread  it  is  removed  in 
ioio,  preventing  it  from  dropping  back  into  the  throat,  which  is  a  very 
disagreeable  accident. 


V  MEULL£RJU:<: 


Fig.  226. — Greenwald's  ethmoid  punch 

5.  The  ethmoid  cells  are  entered  anteriorly  by  means  of  a  small 
punch  (Fig.  226),  making  two  or  three  bites  (Fig.  227). 

6.  This  instrument  is  immediately  replaced   by  a  curette  which 
continues  backward,  breaking  down  one  cell  after  another  (Fig.  228), 


THE  NOSE 


495 


until  the  last  ethmoidal  cell  is  reached  (Fig.  229).  This  can  be 
determined  by  a  slight  percussion  with  the  curette,  by  the  sound  and 
touch  of  harder  bone.  The  curette  now  removes  the  remaining 
lateral  cells  situated  along  the  entire  length  of  the  orbital  plate  of  the 
ethmoid,  knowTi  as  the  lamina  papyracea.  Care  should  be  taken  not 
to  use  too  much  pressure  here,  otherwise  one  might  open  into  the  orbit. 


Fig.  227. — 1,  cut  edge  of  middle  turbinate; 
2,  punch. 


Fig.  228. 


A  greater  danger  in  this  operation  is  the  possibility  of  getting  the 
curette  into  the  olfactory  fissiu-e  and  causing  such  trauma  as  to  produce 
infection  through  the  cribriform  plate  of  the  ethmoid,  thus  opening  the 
lymph  spaces  for  a  possible  meningitis.  One  must  remember  never 
to  go  farther  in  toward  the  septum  in  this  curettage  than  the  line  of 
severance  where  the  middle  turbinate  was  attached. 


Fig.  229. 

7.  Sounding  of  the  Sinuses.— The  frontal  sinus  is  usually  easily 
sounded  unless  pathological  processes,  especially  in  the  bony  structures 
entering  into  the  formation  of  the  nasofrontal  duct,  have  taken  place. 
Having  a  lateral  view  .r-ray  picture  of  the  head  will  aid  the  passing  of 
such  a  sound.  Force  should  never  be  employed  in  this  procedure  and 
the  posterior  wall  of  the  frontal  sinus  must  be  constantly  borne  in 
■  mind  to  avoid  injuring  same.     The  sounds  that  are    employed  are 


496 


SURGERY  OF  THE  NOSE  AND  THROAT 


graduated  in  size  (Fig.  230)  and  one  should  attempt  to  pass  the 
largest  first.  They  are  so  curved  that  when  the  point  of  the  sound  has 
entered  the  cavit\-  of  the  sinus  the  flat  of  the  handle  rests  on  the  upper 
lip  (Fig.  231). 


Fig.  230. — -Ritter's  frontal  situis  nasal  sound. 

In  passing  the  sound  into  the  antrum  the  same  instrument  is 
employed.  Locating  the  thinnest  part  of  the  middle  meatus  with  the 
point  of  the  sound,  one  will  usually  drop  right  into  the  antrum,  with 
but  a  slight  pressure.  The  flat  of  the  handle  of  the  sound  is  directed 
toward  the  septum.  The  largest  sound  of  the  four  is  usually  chosen 
and  passes  without  any  difficulty.  Whether  it  is  the  natural  opening 
of  the  antrum  that  is  sounded,  the  accessory  or  artificial  one,  cannot 


Fig.  231. —  1,  frontal  sinus;  2,  sphenoidal  sinus;  3,  maxillary  sinus. 


be  determined,  and  does  not  make  any  difference.  The  sphenoid  sinus 
is  also  comparatively  easy  to  sound,  especially  when  the  middle  tur- 
binate body  has  been  properly  removed.  The  wTiter  has  devised  a 
set  of  three  spear-shaped  sounds  (Fig.  232)  for  this  purpose.  The 
direction  of  passing  the  sound  is  up  and  backward  at  an  angle  of  about 
45  degrees  to  the  floor  of  the  nose.  "With  the  spear  point  at  that  loca- 
tion a  fairly  firm  pressure  is  exerted  when,  as  a  rule,  the  sound  passes 


THE  NOSE  497 

into  the  sphenoid  sinus.  The  shaft  of  the  sound  is  not  rigid  and  will 
bend  when  more  pressure  is  exerted  than  is  safe.  The  spear  is  flat, 
corresponding  to  the  direction  of  the  flat  bottom  of  the  handle. 

In  withdrawing  the  sound  one  should  turn  the  button  90  degrees, 
which  will  engage  the  shoulders  of  the  spear  against  the  margins  of  the 
opening  of  the  sinus,  and  thus  will  enlarge  it  considerably.  Subse- 
quent sounding  of  the  sphenoid  is  carried  out  by  a  small  olive-tipped 
sound  with  a  rigid  shank. 

8.  Packing  is  usually  unnecessary;  in  fact,  it  is  to  be  avoided  if 
possible,  since  retention  and  secondary  infection  of  the  sinuses  and 
Eustachian  tubes  is  liable  to  take  place.  Should  the  bleeding,  however, 
be  too  brisk  and  with  no  tendency  to  stop,  then  a  packing  may  be 
necessary.  In  such  cases  it  should  only  be  packed  moderately  firmly, 
with  folded  strips  of  gauze  confined  to  the  upper  portion  of  the  nose. 
To  keep  it  in  that  position  the  writer  puts  into  the  inferior  meatus  a 
fairly  firm  rubber  tube,  thus  permitting  some  nasal  breathing. 


Fig.  232. — Beck's  sphenoid  sounds. 

After-treatment. — If  packing  has  been  used  it  should  be  removed  the 
next  day.  If  not  then  there  should  be  absolutely  no  disturbance  of 
the  wounded  surfaces.  No  irrigations  or  swabbing,  with  or  without 
medicaments.  Rest  in  bed  or  in  a  chair  is  advisable  for  two  or  three 
days.  There  is  usually  considerable  reaction  and  blockage  of  the  nose, 
which  should  be  treated  with  the  greatest  of  gentleness.  Application 
of  vaselin  from  a  collapsible  tube  or  the  instillation  of  a  few  drops  of 
adrenalin  solution  is  about  the  limit  of  treatment. 

Immediately  after  operation  the  patient  is  to  be  warned  against 
blowing  the  nose  at  all,  and  the  next  day  only  very  moderately,  owing 
to  danger  of  forcing  air  into  the  orbit  and  cellular  tissue  about  the  lids, 
in  case  of  perforation  of  the  lamina,  or  in  cases  in  which  there  is  a 
dehiscence  from  disease.  Forced  nasal  breathing  exercises  are  to  be 
encouraged  a  day  or  two  after  operation. 

Three  or  four  days  after  operation  one  may  remove  mechanically 
the  crusts  that  are  not  easily  blown  out  by  the  patient,  and  he  is  given 
instructions  how  to  employ  silvol  for  home  treatment,  as  described  on 
page  492.  Vaselin  from  a  collapsible  tube  is  also  employed  until  all 
wounded  surfaces  have  healed,  which  is  usually  at  the  end  of  two  weeks. 
In  the  subsequent  visits  (once  a  week)  the  sounds  are  passed  into  the 
various  sinuses.  Should  the  retention  of  pus  be  discovered  in  any  of  them, 
then  these  are  washed  out  by  means  of  a  washing  apparatus  (Fig.  222), 
employing  normal  saline  or  weak  bicarbonate  of  soda  solution.  The 
VOL.  I — 33 


498  SURGERY  OF  THE  NOSE  AND  THROAT 

use  of  suction  and  vaccines,  as  described  on  page  492,  are  also  to  be 
employed  in  conjunction  with  the  procedure  already  suggested. 

Course. — This  line  of  treatment  is  to  be  continued  for  a  period  of 
two  or  three  months,  providing  there  is  observed  a  constant  improve- 
ment. If,  on  the  other  hand,  the  process  is  at  a  standstill,  or  probably 
worse,  one  will  have  to  decide  on  a  more  radical  procedure,  which 
the  writer  will  discuss  separately  under  each  sinus..  In  cases  of  lues 
or  tuberculosis  the  condition  is  usually  in  the  form  of  pan-sinusitis  and 
marked  changes  in  the  bones,  including  the  hard  palate  and  septum. 

Frontal  Sinus. — To  enlarge  the  nasofrontal  duct  it  has  been  the 
custom  of  the  ^vriter  to  adopt  the  suggestion  of  Mosher,  to  follow  the 
anterior  ethmoidal  region  toward  the  floor  of  the  frontal  sinus  and  open 
into  it.  That  procedure  removed  the  posterolateral  boundary  of 
the  nasofrontal  duct  without  disturbing  the  great  circumference  of 
the  channel  and  prevents  secondary  occlusion  by  granulation  tissue, 
which  follows  when  one  reverses  the  method  and  attempts  to  remove 
the  anterolateral  portion  of  the  duct.  In  this  later  procedure  one  must 
remove  much  denser  bone  (internal  nasal  spine),  which  reacts  much 
more  actively  and  soon  after  operation  causes  greater  obstruction  than 
before  operation.  Following  the  Mosher  procedure,  one  employs  the 
largest  frontal  sinus  probe  for  several  weeks,  when  it  finally  will  remain 
open,  drain  and  ventilate  the  frontal  sinus  very  satisfactorily  in  a  fair 
number  of  cases.  Yet  there  will  be  some  that  will  not  respond  to  that 
treatment.  In  these  cases  one  may  choose  between  the  osteoplastic 
method  of  the  writer  or  the  Lothrop  operation.  Both  of  these  are 
external  operations,  having  much  the  same  advantages,  in  preventing 
deformity  and  retaining  a  patent  frontal  sinus.  The  advantages 
of  the  writer's  method  over  the  Lothrop  is  its  complete  exposure  of 
both  sinuses  to  inspection.  The  Lothrop  operation  is  a  more  radical 
procedure  and  offers  a  permanent  cure  and  prevents  retention. 

Beck's  Osteoplastic  Operation. — Permit  me  now  to  briefly  describe 
the  procedure  which  I  recommended  eight  years  ago  as  an  external 
non-obliterating  operation  in  those  cases  that  are  unsatisfactory  after 
an  intranasal  procedure.  I  might  say  that  I  have  had  to  change  but 
one  item  in  the  technic  since  I  first  presented  it,  and  that  is  the  avoid- 
ance of  the  destruction  of  the  lining  membrane  of  the  internal  nasal 
crest. 

Steps  of  Operation. — 1.  Roentgenogram,  postero-anterior  for  proper 
anatomical  outlines  (Fig.  233). 

2.  Celluloid  model  made  from  tracing  of  frontal  sinus  from  roent- 
genogram (Fig.  234). 

3.  Incision  through  skin  and  subcutaneous  tissue  along  the  upper 
margins  of  the  eyebrows,  and  these  united  across  the  bridge  of  the 
nose  (Fig.  235). 

4.  Dissection  of  the  skin  and  subcutaneous  tissue  flap  upward  and 
placing  of  celluloid  model  over  exposed  area  (Fig.  236). 

5.  Incision  through  the  periosteum  along  the  margin  of  the  cellu- 
loid model  (Fig.  237) . 


THE  NOSE 


499 


Fig.  233. — Roentgenogram  with  outlined  sinus. 


Fig.  234. — Celluloid  model  of  size  and  shape  of  frontal  sinus  with  supra-orbital  margins 

as  landmarks. 


Fig.  235. — Incision  just  below  or  above  margin  of  eyebrow,  down  on  side  of  nose  and 
united  with  opposite  incision  across  the  bridge. 


500 


SURGERY  OF  THE  NOSE  AND  THROAT 


6.  Chisel  and  burr  along  this  lateral  periosteal  incision  from  one 
supra-orbital  margin  to  the  other  into  the  interior  of  the  frontal 
sinus  (Fig.  238). 


Fig.  236. — Skin  and  subcutaneous  tissue  dissected  and  retracted  as  far  as  possible. 
The  incision  over  eyebrow  should  be  extended  outward  as  far  as  necessary  in  each 
indiv-idual  case  depending  on  size  of  sinus.  The  celluloid  model  in  place  and  knife 
incising  periosteum  all  about  the  margins  of  the  model  of  the  outline  of  the  frontal  sinus 
(not  the  supra-orbital  landmarks  of  model). 


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Fig.  237. — Incision  of  periosteum  completed. 


THE  NOSE 


501 


7.  Gigli  saw  engaged  in  the  upper  edge  of  this  incision  and  brought 
down  to  the  level  of  the  supra-orbital  margin,  thus  cutting  the  septum 


Fig.  238. — Chiselling  in  a  beveled  fashion  into  the  sinus  along  the  periosteal  incision. 


Fig.  239. — Gigli  saw  introduced  at  upper  margin  of  the  sinus  and  sawing  downward 
until  supra-orbital  margin  is  reached,  then  drawing  saw  slightly  forward  until  root  of 
nose,  but  not  completely  through  the  bone,  thus  leaving  a  pedicle. 

of  the  frontal  sinus,  then  saw  directed  slightly  upward  to  weaken  the 
osteoperiosteal  pedicle  (Fig.  239) . 


502 


SURGERY  OF  THE  NOSE  AND  THROAT 


8,  Turning  this  osteoplastic  flap  down,  removing  the  pathological 
tissue,  but  carefully  avoiding  exposure  of  bone  to  any  great  extent 
(Fig.  240). 


Fig.  240. — The  anterior  wall  (osteoperiosteal  flap)  turned  down  over  the  nose,  showing 
one  side  with  the  disease  and  the  other  side  already  cleansed.  An  electrically  or  hand- 
driven  burr,  enlarging  the  frontal  sinus  outlet  in  action. 

9.  Enlarging  outlet  of  the  sinus  in  the  nose,  backward  and  outward, 
by  means  of  an  electrically  driven  burr  (Fig.  240),  carefully  avoiding 
the  internal  nasal  crest  by  use  of  the  Halle  protector  (Fig.  241). 


Fig.  241. — Halle  cranial  protector. 


10.  Semisolid  rubber  tubing  inserted  into  the  outlet,  one  end  coming 
out  at  or  near  the  nostril,  the  upper  end  at  the  beginning  of  the  outlet 
of  the  frontal  sinus  or  infundibulum.  Through  this  tube  a  strip  of 
gauze  is  packed,  the  upper  end  loosely  filling  in  the  cavity  of  the 
sinus  (Fig.  242). 

11.  Osteoplastic  flap  brought  back  into  position  and  the  skin  and 
subcutaneous  tissue  flaps  brought  down  and  sutured  or  closed  by  use  of 
clips. 


THE  NOSE 


503 


After-treatment.— On  the  second  day  remove  the  gauze  and  on  the 
fifth  day  the  tube.  No  further  drainage  is  necessary.  Subsequently, 
but  not  before  three  weeks,  wash  the  sinus  with  normal  salt  solution  or 
injection  of  bismuth  paste  into  the  sinus  may  be  done. 


Fig.  242.- 


-In  one  side  the  rubber  tube  without  gauze  and  the  other  loosely  packed  with 
gauze,  the  end  passing  within  the  rubber  tube  into  nose. 


Fig.  243. — Incision  for  unilateral  operation.  In  such  cases  the  osteoperiosteal  flap 
is  made  either  by  the  aid  of  a  chisel  or  fine  electric  burr  and  the  small  bony  pedicle 
broken  over.  The  skin  and  subcutaneous  incision  may  be  made  the  same  as  in  the 
double  operation,  but  the  advantage  of  opening  only  one  side  when  only  one  side  is 
involved  is  obvious. 


504 


SURGERY  OF  THE  NOSE  AND  THROAT 


In  criticism  of  the  procedure  I  would  say  that  if  only  one  side  is 
affected  one  may  take  off  just  the  one-half  of  the  anterior  surface  of  the 
sinus,  that  is,  employ  the  fine  burr  or  chisel  to  follow  a  celluloid  model 
of  just  the  size  of  the  sinus  to  be  exposed  (Fig.  243).  This  is  an  objec- 
tion in  that  one  may  infect  the  otherwise  healthy  sinus.  I  have  no 
doubt  that  I  have  done  this  very  thing  several  times  without  any 
untoward  results,  because  the  procedure  cured  the  infected  sinus, 
and  thus  prevented  reinfecting  the  healthy  sinus  to  any  extent.  As 
to  exact  statistics,  I  will  state  that  since  1908  I  have  performed  this 
operation  thirty-one  times,  with  an  apparent  cure  in  27  cases.  On 
two  occasions  I  operated  away  from  home  and  never  heard  whether 
the  results  were  satisfactory  or  not;  the  other  two  sinuses  had  to  be 
reoperated  by  the  Killian  method.  These  were  the  early  cases  in  which 
I  made  large  openings  into  the  nose,  taking  away  some  of  the  internal 
nasal  crest,  and  in  which  the  mucous  membrane  of  the  entire  circum- 
ference of  the  outlet  of  the  frontal  sinus  was  destroyed.  These  reopera- 
tions would  have  been  good  cases  for  the  Lothrop  operation. 


-^■^^^^^^^^ 


^^i    ^^ 


Fig.  244. 


Lothrop  Operation. — The  principles  involved  in  the  technic  are  to 
convert  both  frontal  sinuses  into  one  cavity  by  taking  away  the  septum 
between  the  sinuses,  to  continue  the  removal  of  the  septum  of  the  nose 
at  the  root  of  the  nose,  and  a  bit  farther  down.  Thus  one  may,  after 
the  operation,  pass  sounds  from  the  right  side  of  the  nose  into  the 
left  frontal  sinus,  or  vice  versa,  which  are  now  one  (Fig.  249).  The 
resulting  opening  becomes  subsequently  covered  with  healthy  mucous 
membrane,  and  can  never  close,  because  it  is  too  large  to  become 
approximated. 

Technic. — Operation  may  be  performed  under  either  local  or  general 
anesthesia. 

1.  An  incision  one  and  one-half  inches  long  at  the  inner  corner  of 
the  eye,  at  the  junction  of  the  nose,  down  to  the  bone  (Fig.  244).  Do 
not  go  through  eyebrow. 


THE  NOSE 


505 


2.  Dissect  off  periosteum  in  both  directions  and  introduce  self- 
retaining  speculum  (Fig.  245). 

3.  By  the  aid  of  an  electrically  driven  burr,  take  away  a  plate  of 
bone  (gouges,  chisels  and  bone  forceps  may  also  be  employed),  about 
the  size  of  a  dime  at  the  upper  inner  angle  of  orbit  (Fig.  246). 

4.  A  small  oval  burr  takes  down  the  interfrontal  sinus  septum. 


Fig.  246. 


Fig.  247. 


-^^^^^^^^^^^^^     ;;'''■  ^.^^ 


Fig.  248. 


Fig.  249. 


5.  With  a  heavier  oval  burr  remove,  by  way  of  the  external  opening 
and  through  the  nose,  the  thick  nasal  spine  of  the  frontal  bone  and  the 
perpendicular  plate  of  the  ethmoid  (septum),  taking  great  care  to  keep 
well  to  the  front,  toward  the  nasal  bones,  and  avoiding  injury  of  the 
cribriform  plate  of  the  ethmoid  (Figs.  247  and  248). 

6.  Close  the  wound  by  primary  suture. 


506 


SURGERY  OF  THE  NOSE  AND  THROAT 


After-treatvient. — For  the  next  week  there  is  practically  nothing  to 
do  except  the  removal  of  the  stitches.  The  edema  of  the  lids  requires 
no  special  attention.  When  the  acute  symptoms  of  the  operation 
have  disappeared  then  the  frontal  sinus  should  be  probed  from  either 
side  of  the  nose  until  the  wound  has  healed  by  a  mucous  membrane 
covering  (Fig.  249). 

Radical  Frontal  Sinus  Operation  (Killian). — There  will  still  remain  a 
fair  number  of  cases  of  chronic  frontal  sinus  disease  that  will  not 
recover  following  the  operative  procedures  just  described,  or  there 
may  be  such  marked  progress  in  the  pathological  changes  of  the  sinus 
to  begin  with,  that  the  radical  operation  must  be  performed.  The 
principles  underlying  this  operation  are:  (a)  Complete  obliteration 
of  the  cavity,  with  the  least  amount  of  deformity  possible.  The  first 
procedure  can  always  be  accomplished,  but  the  second  will  depend 
upon  the  size  of  the  sinus,  both  laterally  as  well  as  its  depth.  It  is 
very  important  that  the  supraorbital  border,  known  in  the  operation 
as  the  bridge,  should  be  well  preserved,  and  yet  if  too  much  of  the  bone 
is  retained  it  may  defeat  the  purpose  of  the  operation. 


^--^^^  \  ^ 


yx  '"  V/ 


Fig.  250. 


Fig.  251. 


Technic. — Usual  external  preparation  of  the  field.  Do  not  shave 
the  eyebrows.     Either  local  or  general  anesthesia  may  be  employed. 

1.  Incision  above  or  below  the  eyebrow,  but  not  through  it,  and 
continued  down  the  side  of  the  nose.  Ligate  the  supra-orbital  vessels 
(Fig.  250).  If  below  the  eyebrow  there  will  be  a  more  restricted  field 
and  more  difficulty  in  exposure,  especially  in  a  large  frontal  sinus. 

2.  Dissect  all  tissues  with  periosteum  until  the  greater  part  of  the 
anterior  surface  of  the  sinus  is  exposed,  and  retract  forcibly.  The 
retraction  should  be  forward  rather  than  upward  and  the  subsequent 
removal  of  bone  is  performed  in  a  sort  of  a  pocket  (Fig.  251).  The 
reason  for  this  is  the  limited  incision.  The  orbital  contents  at  the 
internal  canthus  are  dissected  downward  and  held  by  a  retractor. 


THE  NOSE 


507 


3.  By  the  aid  of  an  electrically  driven  burr  (ball)  the  entire  anterior 
bony  wall  of  the  sinus  as  well  as  the  floor  are  removed,  leaving  a  strip 
of  bone  (supraorbital  border)  about  one-eighth  of  an  inch  in  thickness 
(Fig.  252).  There  is  no  danger  of  its  being  fractured,  since  the  orbital 
plate  of  the  frontal  bone  is  not  attacked  in  as  great  an  extent  as  it 
formerly  was  in  this  operation. 

4.  The  entire  lining  membrane  of  the  sinus  is  thoroughly  removed 
by  a  curette,  and  subsequently  the  burr  plays  lightly  over  the  surface 
so  as  to  hasten  the  formation  of  granulations,  and  thus  causing  oblitera- 
tion. The  mucous  membrane  should  be  thoroughly  removed  from  the 
infundibulum  toward  the  nose,  so  as  to  prevent  retention  in  that  portion 
of  the  nose. 

5.  After  primary  suture  of  the  incision  the  tissues  are  firmly  pressed 
into  the  cavity  and  a  firm  pressure  bandage  is  applied. 


/.^..ujpljJWil 


Fig.  252. 


Fig.  253. 


After-treatment. — ^There  is  usually  nothing  to  do  for  the  first  week 
except  to  remove  the  stitches.  After  the  bandage  is  removed  the 
patient  should  be  warned  against  forcibly  blowing  the  nose,  thus 
avoiding  getting  the  secretions  into  the  cavity  and  preventing  oblitera- 
tion. In  case  the  deformity  resulting  from  the  obliteration  be  too 
large,  especially  if  both  sinuses  had  to  be  operated  upon,  there  can  and 
should  be  performed  a  plastic  operation  to  correct  this  deformity.  This 
should  not  be  done  until  one  is  certain  that  the  obliteration  is  complete 
and  the  area  is  sterile.  The  best  results  in  these  cases  have  been  from 
the  use  of  fat  and  fascia  from  abdomen  or  leg.  Never  paraffin  or  any 
other  foreign  substances. 

Antrum  of  Highmore. — ^There  are  many  more  methods  of  operating 
on  the  antrum  than  upon  any  other  sinus,  but  several  of  these  have 
fallen^into  disrepute  and  the  others  are  more  or  less  modifications,  con- 
sequently the  writer  will  confine  himself  to  the  description  of  operative 
procedures  that^to  him  appear  the  most  practical  and  the  ones  employed 
routinely  by  him.    There  are  two  ways  of  attack: 


508 


SURGERY  OF  THE  NOSE  AND  THROAT 


1.  By  way  of  the  nose. 

2.  Under  the  Hp. 

The  majority  of  rhinologists  prefer  the  nasal  route,  however,  every- 
one admits  that  the  method  under  the  Up  offers  the  best  chance  of 
inspection  and  properly  opens  into  the  nose. 


Fig.  254. 


Technic. — Intranasal  route.  1.  Local  applications  of  cocain,  as 
in  other  intranasal  operations.  By  hypodermic  injections  of  1  per 
cent,  apothesin  the  anterior  surface  of  the  superior  surface  of  the  super- 
ior maxilla  (periosteum)  is  anesthet'zed  (Fig.  254),  as  is  also  the  inferior 
meatus  (Fig.  255). 


Fig.  255. 


Fig.  256. 


2.  Incision  within  the  vestibule  over  the  bony  edge  of  the  superior 
maxilla  (aperatura  pyriformse)  (Fig.  255). 

3.  Periosteal  elevation  lifting  off  the  mucoperichondrium  of  the 
inferior  meatus  and  an  immediate  introduction  of  a  right  angular  flat 
retractor  (Figs.  256  and  257). 


THE  NOSE 


509 


4.  Elevation  of  the  periosteum  over  the  anterior    surface  of  the 
superior  maxilla  for  a  distance  of  one  and  one-half  inches.     A  similar 


Fig.  257. — Freer's  long  retractor. 

retractor  introduced  into  this  wound.    Forcible   retraction  on  these 
two  retractors  will  expose  the  part  of  the  superior  maxUla  to  be  attacked 

(Fig.  258). 


=^=^^5^ 


Fig.  258. 


5.  By  the  aid  of  a  bmr,  chisel  and  rongem-s  (Fig.  259)  a  piece  of 
bone,  one-half  inch  in.  diameter,  is  removed,  giving  a  very  good  inspec- 
tion of  the  antral  cavitv. 


Fig.  259. — Lombard  bone  forceps. 


6.  By  the  aid  of  a  nasal  forceps  (Fig.  206)  some  of  the  bone  of  the 
nasal  wall  of  the  antrum  (inferior  meatus)  is  fmther  removed  for  about 
one-quarter  of  an  inch. 


.10 


SURGERY  OF  THE  XOSE  AXD  THROAT 


7.  The  parts  are  allowed  to  fall  together  and  a  fairly  stiff  rubber 
tube,  one-quarter  of  an  inch  in  diameter  and  about  one  inch  long,  is 
passed  into  the  antrum  and  allowed  to  protrude  from  the  nostril. 
This  tube  should  remain  in  place  for  about  forty-eight  hours,  when  the 
opening  into^the  antrum  will  be  established  and  remain. 


Fig.  260. 


Fig.  261. — Second  retractor  in  place. 


Sublabial  Operation. — 1.  Incision  from  the  center  to  the  first  molar 
tooth  through  the  mucous  membrane  underhing  tissues^(Fig.  260). 
This  incision  should  not  be  made  in  the  gingival  tissues  but  farther 
back,  since  suturing  is  thus  facilitated  and  more  rapid  healing  is 
obtained. 


Fig.  262. 


Fig.  263. — 1,  middle  turbinated; 
2,  inferior  turbinated. 


2.  Firm  traction  forward  rather  than  upward  (as  in  the  Killian 
operation),  by  means  of  a  second  retractor  exposing  the  anterior  surface 
of  the  superior  maxilla  (canine  fossa)  (Fig.  261). 

3.  Removal  of  a  piece  of  bone  either  by  burr  or  gouges  and  rongeurs 
as  large  as  a  nickel  (Fig.  262). 


THE  NOSE 


511 


4.  If  there  are  polypi  or  other  diseased  tissues  present  they  should 
be  carefully  removed  without  sacrificing  the  linings  of  the  cavity. 

5.  Over  the  prominent  portion  of  the  inferior  meatus,  well  forward, 
a  piece  of  bone  is  removed  the  size  of  a  dime  (Fig.  263).  The  mucous 
membrane  lining  the  nose  over  this  bony  area  just  removed  should  be 
saved,  if  possible,  and  utilized  to  fold  over  the  lower  edge  of  the  bony 
incision  of  this  inferior  meatal  opening  just  made. 

6.  A  rubber  tube  similar  to  the  one  employed  in  the  intranasal 
method  is  passed  through  the  naso-antral  wall,  out  through  the 
nostril  (Fig.  264). 

7.  The  wound  sublabially  is  completely  closed  by  three  or  four 
interrupted  sutures. 

1 


Fig.  264. — 1,  drainage  tube. 


Fig.  265. — 1,  infraorbital  margin; 
2,  infraorbital  foramen. 


After-treatment — ^The  tube  is  removed  after  forty-eight  hours  by 
way  of  the  nose,  and  the  stitches  in  about  four  days. 

In  only  a  small  proportion  of  cases  in  which  either  of  these  opera- 
tions has  been  performed  will  there  remain  symptoms  of  antrum 
disease  severe  enough  to  require  more  radical  measures,  as  was  true  in 
the  frontal  sinus.  The  writer  has  developed  a  technic  of  obliterating 
the  antrum  without  necessarily  resorting  to  the  deforming  operations 
advocated  by  Shede  or  Jansen. 

Beck's  Obliteration  Operation. —  Technic. — 1.  Expose  the  entire  ante- 
rior and  lateral  portion  of  the  superior  maxilla  through  the  sublabial 
route.  This  requires  severing  the  cartilaginous  attachment  of  the  nose 
on  one  side  from  the  apertura  pyriformse  (Fig.  265). 

2.  Find  the  infraorbital  foramen  and  nerve. 

3  Inject  the  infraorbital  nerve  by  means  of  cocaine,  4  per  cent, 
(novocain  or  apothesin  will  not  suffice),  and  remove  the  nerve  by 
neurectasis. 

4.  Remove  the  greater  portion  of  the  anterior  and  lateral  portion 
of  the  superior  maxilla,  in  other  words,  the  two  walls  of  the  antrum 
(Fig.  266). 


512  SURGERY  OF  THE  NOSE  AND  THROAT 

5.  Remove  thoroughly  all  the  mucous  membrane  of  the  antrum. 

6.  By  the  aid  of  the  burr  remove  the  superficial  layers  of  the  bone  of 
the  remaining  surfaces  of  the  antrum,  to  promote  granulation  formation. 

7.  Remove  the  greater  portion  of  the  naso-antral  wall  of  the  inferior 
meatus,  including  the  mucous  membrane,  if  that  had  not  been  done 
before. 

8.  Closure  of  subliabial  incision  by  six  interrupted  stitches. 

9.  A  firm  ball  of  cotton,  about  the  size  of  a  small  apple,  is  placed  over 
the  anterior  lateral  sm-face  of  the  face  and  a  firm  bandage  applied, 
thus  aiding  obliteration.     This  bandage  is  left  on  for  several  days. 

After-treatment. — Remove  the  stitches  in  four  or  five  days.     After 
about  ten  days  begin  to  inject  bismuth  paste  into  the  remaining  cavity, 
not  obliterated  by  the  soft  tissues  overlying 
the  antrum.    These  injections  are  carried  out 
through  the   inferior  meatal   opening,   about 
three  times  a  week,  until  the  cavity  is  entirely 
obliterated,  which  may  take  from  one  to  six 
months,  depending  upon  the  size  of  the  cavity. 
Ethmoidal  Labjrrinth. — In  case  the  primary 
intranasal  exenteration  of   all  these    ethmoi- 
dal cells  is  not  followed  by  the  cessation  of  dis- 
charge, one  will  have  to  think  of  one  or  both  of 
the  following  conditions: 
Fig.  266.  1.  That  there  are  still  some  cells  which  have 

not  been  opened  for  proper  drainage  and  venti- 
lation, or  the  disease  is  of  a  serious  pathological  nature  as,  for  instance, 
a  necrotic  process  of  pyogenic,  luetic  or  tuberculous  etiology.  In  the 
event  of  the  former  condition  one  will  reoperate  even  more  than  once, 
until  finally  the  process  is  brought  to  a  standstill.  This  can  be  done 
intranasally,  since  there  are  very  few  ethmoid  cells  that  cannot  be 
reached  by  that  route  mth  safety. 

2.  In  the  presence  of  a  persistent  suppurative  process  the  same  is 
more  likely  to  be  due  to  a  bone  disease.  Then  appropriate  attention 
should  clear  up  the  condition  in  time.  Some  of  the  most  brilliant  results 
in  arresting  the  discharge  are  in  luetic  cases.  Blood  examination  is 
frequently  negative  as  to  the  Wassermann  reaction.  The  use  of  the 
mercury  or  KI  treatment  may  have  been  of  little  value  whereas 
salvarsan  acts  wonderfully  well. 

Sphenoid  Sinus. — This  cavity,  as  a  rule,  responds  very  favorably 
to  surgical  treatment  by  simple  opening,  ventilating  and  draining. 
However,  like  the  rest  of  the  sinuses,  there  are  times  when  more  active 
surgery  or  treatment  is  necessary  to  bring  about  resolution  or  cessation 
of  discharge.  One  of  the  reasons  for  this  difficulty  is  the  unusual 
anatomical  malformation  or  extension  that  exists  at  times.  Prentiss, 
of  the  Iowa  University,  anatomical  department,  has  shown  in  a  fair 
number  of  specimens  the  extensions  of  the  sphenoid  sinus  occur  deep 
down  and  back  toward  the  clivus  and  in  the  direction  of  the  pterygoid 
plates,  also  laterally  into  the  wings  of  the  sphenoid. 


THE  PHARYNX  513 

Operation. — ^The  more  extensive  procedure  is  to  remove  the  greater 
part  of  the  anterolateral  wall  well  into  the  posterior  ethmoid  region. 
This  is  accomplished  by  any  of  a  variety  of  the  sphenoidal  punches. 
There  is  one  precautionary  measure  in  the  removal  of  the  antero- 
lateral wall,  and  that  is  to  guard  against  the  injuring  of  the  spheno- 
palatine artery,  which  lies  laterally  and  very  much  lower  than  one  is 
ordinarily  called  upon  to  extend  the  incision.  Only  in  those  anomalous 
cases  mentioned  before,  in  which  one  would  like  to  follow  the  process 
and  explore  it,  is  there  much  danger  of  wounding  this  artery.  In 
case  of  injury  of  this  artery,  its  control  is,  as  a  rule,  possible  by  firm 
nasal  packing. 

Whenever  the  disease  is  of  osteal  rather  than  membranous  nature, 
or  both,  like  a  rarefied  osteitis  of  septic,  leutic  or  tuberculous  etiology, 
one  has  recourse  to  non-surgical  measures.  These  conditions  are  usually 
of  severe  form,  in  that  great  pain  (in  the  head)  is  present,  accompanied 
usually  by  ocular  s^niptoms  referable  to  the  optic,  motor  and  SATupa- 
thetic  nerves.  To  determine  that  the  bone  is  soft,  one  can  employ  a 
diagnostic  s^onptom,  original  with  the  "^Titer,  who  has  demonstrated 
its  value  in  about  half  a  dozen  eases  of  this  type.  While  one  inspects 
the  sphenoid  sinus  area,  an  assistant  compresses  both  internal  jugular 
veins  and  carotid  arteries  along  the  sternocleidomastoid  muscles.  There 
will  be  observed  at  first  a  pulsation  and  soon  after  an  outpouring  of 
pus,  due  to  the  distention  of  the  internal  carotid  arteries  and  cavernous 
sinuses  situated  in  close  proximity  of  the  sphenoidal  sinus. 


THE  PHARYNX. 

Anatomically  the  pharynx  is  divided  into : 

A.  Nasopharynx  or  postnasal  space,  better  still,  epipharynx. 

B.  Oropharynx  or  pharyngeal  space  proper,  better  still,  meso- 
pharynx. 

C.  Epipharynx,  region  of  the  base  of  the  tongue,  better  still,  h3T)o- 
pharynx  (Fig.  267). 

Epipharynx. — Structures  to  be  considered  from  the  surgical  point 
of  view  in  the  epipharynx  are  the  adenoid  tissues  at  the  vault,  usually 
spoken  of  as  adenoid  vegetations  and  the  pharyngeal  ends  of  the 
Eustachian  tubes.  Extension  of  pathological  processes  from  the  nose, 
particularly  the  sphenoid  cavity,  and  extension  downward  from  the 
hypophysis  must  also  be  borne  in  mind. 

The  consideration  of  the  adenoid  disease  will  be  taken  up,  together 
with  tonsillar  affections,  since  the  surgical  treatment  of  both  of  these 
is  usually  carried  out  simultaneously. 

Tumors. — Occasionally  one  meets  with  tumors,  one  of  the  most 
frequent  affections  confined  to  the  epipharjmx.  The  origms  of  these 
are  either  from  the  vault  in  the  region  of  the  adenoid  or  laterally  from 
the  wall  of  the  sphenoid  sinus.    These  tumors  are  of  comparatively 

VOL.  I — 33 


514 


SURGERY  OF  THE  NOSE  AND  THROAT 


slow  growth,  cause  very  few  early  sjniptoms.  At  first  there  may  be  an 
interference  with  nasal  respiration  of  one  or  both  nostrils,  and  a  change 
in  the  voice  by  a  sort  of  a  dead  tone  or  a  nasal  obstructive  twang. 
Pain  radiating  to  the  side  of  the  head  and  face  often  follows.  Patients 
usually  experience  difficulty  in  hearing  on  the  side,  when  the  tumor 
encroaches  upon  the  Eustachian  orifice,  and  complaints  of  very  severe 
noise  (tinnitus)  are  not  at  all  uncommon.  Inspection  usually  reveals 
a  limited  motion  up  and  back  of  the  soft  palate,  in  saying — "ah"  or 
upon  reflex  action  when  touching  the  soft  palate. 

Postrhinoscopic  examination,  with  a  mirror,  as  well  as  direct  exami- 
nation through  a  thoroughly  shrunken  nostril,  will  reveal  the  tumor. 
Palpation  with  the  finger,  postnasally  as  well  as  directly  against  the 
soft  palate,  will  reveal  the  consistency,  location  and  size  of  the  growth 
as  well  as  to  whether  it  pulsates,  bleeds  or  is  painful.  The  pathological 
condition  most  frequently  found  is  that  of  fibrosarcoma.  Abscesses, 
aneurysm  or  carcinoma  are  much  less  frequently  met  with  in  the 
epipharjTix, 


Fig.  267. — 1,  frontal  siniis;  2,  ant.  pillar;  3,  post,  pillar;  4,  sphenoidal  sinus;  5,  post, 
edge  of  nasal  septum;  6,  fossa  of  Rosenmiiller;  7,  pharj-ngeal  tonsil;  8,  Eustachian  tube; 
16,  hjTJophysis. 

Treatment. — ^The  treatment  giving  the  best  results  is,  of  course,  the 
surgical.  The  greatest  difficulty  has  been  the  firmness  with  which  these 
tumors  are  attached  and  the  severe  hemorrhage  that  results  immediately 
at  the  severance  of  the  growth  from  its  attachments. 

Technic. — Cocainizing  by  topical  applications  of  pure  cocaine  flakes, 
as  well  as  the  peripheral  injection  of  the  tumor,  of  a  1  per  cent,  solution 
of  cocaine,  will  usually  suffice.  The  patient  is  best  placed  in  a  semi- 
reclining  position  on  a  table  and  a  suction  apparatus  at  hand  to  remove 
the  blood  and  secretion,  so  that  the  patient  needs  to  make  no  effort  in 
clearing  the  throat. 


THE  PHARYNX 


515 


1.  Pass  a  small  rubber  urethral  catheter  through  each  nostril,  which 
has  also  been  cocainized,  and  withdraw  the  ends  through  the  mouth 
(Fig.  268) .  This  is  for  the  purpose  of  drawing  the  soft  palate  forward 
and  obtaining  a  very  clear  view  of  the  epipharynx. 

2.  By  means  of  a  full,  curved,  strong  scissors  the  growth  is  severed 
from  its  firm  attachment  and  the  free  flow  of  blood  is  sucked  up,  and 
then  with  a  full,  curved,  artery  forceps,  grasp  the  bleeding  points. 

3.  Grasping  the  partially  severed  tumor  by  a  strong  vulsellum,  a 
very  heavy  wire  snare  loop  is  passed  around  the  greater  circumference 
of  the  tumor  and  removed  with  the  aid  of  the  snare.  It  is  not  at  all 
infrequent  that  the  wire  breaks  or  slips  out  of  the  snare,  owing  to  the 
firmness  of  the  tumor. 

4.  It  is  well  to  have  at  hand  a  galvanocautery,  so  that  any  mass 
remaining  may  be  destroyed  by  that  method. 


Fig.  268. 


5.  Should  bleeding  be  very  profuse  and  not  controlled  by  the  method 
mentioned,  then  a  very  firm,  postnasal  tampon  must  be  introduced. 
This  is  very  easily  done  by  attaching  the  ends  of  a  piece  of  tape,  which 
holds  the  tampon  to  each  end  of  the  rubber  catheter,  which  are  with- 
drawn through  the  nose. 

After-treatment.- — If  a  tampon  has  been  employed  then  it  should  be 
removed  on  the  next  day,  but  often  it  is  necessary  to  reintroduce  a 
less  firm  one,  because  oozing  may  start  up  again. 

The  raw  surface  takes  several  days  to  heal  and  the  application  of 
silvol  by  way  of  the  nose  is  the  best  method  of  medication. 

Beck's  Technic.  —  Tilt  the  head  well  back,  preferably  over  the 
edge  of  the  bed  or  back  of  a  chair,  and  allow  about  two  medicine 
dropperfuls  of  silvol,  5  per  cent.,  to  trickle  slowly  into  the  naso- 
pharynx, until  the  patient  feels  it  escaping  lower  down  into  the 
throat.    Remaining  in  this  position  for  one  or  two  minutes  the  head  is 


51G 


SURGERY  OF  THE  NOSE  AXD  THROAT 


brought  into  the  extreme  opposite  position  (forward  and  downward) 
for  about  ten  seconds  (Fig.  269).    Repeating  this  procedure  about 


Fig.  269. 


one-half  dozen  times  a  day  will  aid  in  the  healing  of  the  large  raw 
surface.  Silver  nitrate,  full  strength  or  fused  on  a  probe  as  a  bead 
applied  to  the  actual  granulation,  may  become  necessary. 


THE  PHARYNX  5l7 

Radium  Treatment. — ^This  may  be  applied  without  any  previous 
operative  procedure  or  after  the  greater  part  of  the  growth  has  been 
removed. 

Technic. — Cocainize  and  retract  the  palate  as  if  about  to  operate. 

1.  The  use  of  platinum  needles,  each  containing  12|  mlgrs.  of  radium 
element,  are  pushed  into  the  tumor  from  three  to  five  directions.  From 
37|  to  62|  mlgrs.  of  radium  are  thus  inserted  within  the  growth. 

2.  Allow  this  to  remain  from  four  to  eight  hours,  depending  upon 
the  nature  of  the  histological  pathology — if  fibrosarcoma,  four  hours; 
if  myxosarcoma,  six  to  eight  hours. 

3.  After-treatment.- — The  reaction  from  radium  should  receive  the 
same  attention  as  that  following  operations,  namely,  silvol  by  way 
of  the  nose. 

The  entire  growth  is  seldom  destroyed  by  one  application.  As  a 
matter  of  experience  and  from  reference  to  the  literature  one  learns 
that  it  may  take  as  many  as  six  seances  before  the  entire  growth  is 
destroyed.  The  repetition  of  the  treatment  depends  on  the  amount  of 
reaction  resulting  from  the  previous  application.  Usually,  however, 
within  two  weeks  the  necrotic  surface  will  clear  up  and  the  marked 
reaction  disappear.  If  the  growth  has  been  operated  upon,  and  it  is  de- 
sired to  use  the  radium  to  follow  up  the  surgical  intervention,  then  it  is 
best  to  employ  the  radium  in  capsules.  These  are  placed  within  a  rubber 
tube  and  drawn  back,  as  one  would  the  postnasal  tampon,  to  control 
hemorrhage.  One  must  see  clearly  that  the  tube  containing  the 
radium  is  in  close  contact  with  the  raw  surface.  The  same  dosage  is 
employed  as  in  the  needles,  but  it  is  allowed  to  remain  longer  because 
the  capsules  are  usually  covered  with  a  thicker  filter.  In  the  few  cases 
treated  by  the  writer  he  permitted  the  capsules  to  remain  overnight. 
This  postoperative  treatment  with  radium  should  not  be  started  until 
all  oozing  has  stopped  and  the  necrotic  surface  .cleaned  off. 

Nasal  Polypi. — Particularly  from  the  sphenoid  sinus  or  posterior 
ethmoid  cells  do  we  find  a  solitary  polyp  reaching  into  the  postnasal 
space  and  there  develops  to  a  much  larger  size  than  it  does  within  the 
nasal  cavity.  Examination  with  the  postrhinoscopic  mirror  wall  show 
it  to  be  grayish  in  appearance  and  palpation  finds  it  to  be  freely 
movable  and  very  soft. 

Treatment. — It  is  best  attacked  by  way  of  the  nasal  cavity,  combined 
with  the  pharynx.  A  nasal  snare  is  passed  into  the  postnasal  space, 
and  by  aid  of  the  finger  with  the  soft  palate  retracted  forward  the  tumor 
is  pushed  into  the  loop  of  the  snare.  Drawing  down  firmly  but  not 
cutting  it  oif ,  the  snare  is  pulled  on  steadily  until  the  growth  gives  way. 
Thus  one  will  not  only  remove  the  growth  within  the  postnasal  space 
but  the  diseased  membrane  from  the  sinuses,  in  the  form  of  a  pedicle. 
Fig.  270,  shows  one  of  this  variety  of  polypi  properly  eradicated. 

The  Eustachian  orifices  are  usually  involved  in  pathological  processes 
from  contiguous  parts,  as  just  described  in  tumors  or  much  more  fre- 
quently in  disease  of  the  tonsils  and  adenoids  or  inferior  turbinates. 
These  are  in  the  form  of  obstruction  either  direct  or  by  congestion,  due 


518  SURGERY  OF  THE  NOSE  AND  THROAT 

to  circulatory  interference.  As  soon  as  these  pathological  processes 
are  corrected  the  symptoms  referable  to  the  Eustachian  tube  openings 
will  disappear.  The  most  prominent  symptoms  are  referable  to  the 
middle  ear. 


Fig.  270. — Sphenoid  polyp,  showing  pedicle. 

Mesopharynx.  —  In  recent  years  there  has  been  such  a  definite 
belief  established  in  the  fact  that  the  tonsils  which  are  situated  within 
this  space  cause  much  trouble  when  they  are  diseased,  and  the  thorough 
removal  of  them  is  so  often  followed  by  brilliant  results  that  it  behooves 
one  to  be  well  versed  in  the  surgical  anatomy  of  these  parts,  if  he 
expects  to  do  good  tonsillar  surgery. 

The  tonsil  surrounded  by  its  fibrous  capsule  is  wedged  in  between 
the  two-  muscular  folds  known  as  the  anterior  and  posterior  pillars. 
Where  these  two  pillars  begin  to  diverge  above  they  form  a  membrane 
known  as  the  plica  semilunaris  which  in  most  instances  hides  the  upper 
portion  of  the  tonsil.  The  remainder  of  this  fold,  called  the  plica 
triangularis,  can  alwaj^s  be  seen  near  the  base  of  the  tongue,  running  from 
the  anterior  pillar  back  towards  the  posterior  pillar.  This  plica  is 
differently  developed  in  different  individuals  and  it  is  important  to 
remember  that  after  the  tonsil  has  been  removed;  by  compensatory 
hypertrophy,  it  often  fills  the  space  created  by  the  tonsillectomy,  and  to 
the  uninformed  appears  to  be  a  part  of  the  tonsil;  in  other  words,  an 
imperfect  operation.  Nothing  could  be  more  incorrect  than  to  mistake 
it  for  a  remnant  of  the  tonsil.  When  depressing  thebase  of  the  tongue 
one  will  observe,  in  many  cases,  quite  a  mass  of  l^inphoid  tissue  below  the 
plica  triangularis  which  runs  right  into  another  mass  of  lymphoid  tonsil. 
Special  attention  is  called  to  this  lymphoid  tissue,  because  after  a  very 
thorough  tonsillectomy  it  not  infrequently  occurs  that  the  l^nnphoid 
tissue  undergoes  marked  compensatory  hypertrophy  and  also  looks  as 
if  some  of  the  tonsil  was  not  removed.  Only  that  portion  of  the  faucial 
tonsil  is  exposed  to  view  which  contains  crypts  and  is  covered  by  epi- 
thelium.    The  capsular  part  is  entirely  hidden.     The  capsule  is  very 


THE  PHARYNJt 


510 


loosely  attached  to  the  deep  layer  of  the  deep  fascia  of  the  neck  and 
after  a  clean  tonsillectomy,  especially  by  the  Sluder  method  or  many 
of  its  modifications,  it  will  be  seen  as  a  perfect  cavity  with  absolutely 
no  injm'y  to  the  fascia  or  any  of  its  neighboring  muscles.  As  a  matter 
of  fact  in  many  cases  one  can  observe  small  venous  channels  traversing 
this  cavity  without  the  least  injury  to  these  vessels.  The  blood  supply 
to  the  tonsils  is  received  principally  from  branches  of  the  external 
carotid  artery  (Fig.  271)  and  is  distributed  as  follows  (Fig.  272). 


Fig.  271. — 1,  tonsillar  branch  of  facial 
art.;  2,  occipital  art.;  3,  int.  carotid  art.; 
4,  lingual  art.;  5,  ext.  carotid  art.;  6, 
spinal  accessorj-  nerve;  7,  common  carotid 
art. ;  8,  hj'poglossal  nerve  (descending) ; 
9,  pneumogastric  nerve;  10,  capsule  of 
palatine  tonsil;  11,  facial  art.;  12,  hypo- 
glossal nerve;  13,  sup.  thjToid  art. 


Fig.  272. — -1,  sphenopalatine  branch; 
2,  tonsillar  art.  (facial);  3,  post,  pillar; 
4,  ant.  pillar;  5,  recurrent  branch  of 
lingual  art.;  6,  palatine  branch  of  as- 
cending pharj'ngeal  art. 


To  the  upper  pole  by  the  palatine  branch  of  the  sphenopalatine. 

To  the  lower  pole  by  the  palatine  branch  of  the  ascending  pharyngeal. 

To  its  middle  runs  the  tonsillar  branch  of  the  fascial,  and  anteriorly 
and  low  down  is  the  twig  from  the  lingual.  In  performing  tonsillec- 
tomy these  arteries  are  always  severed  so  that  there  must  of  necessity 
always  be  bleeding;  however,  in  the  majority  of  the  instances,  these 
vessels  are  very  small  and  retract  very  quickly  and  bleeding  stops 
spontaneously.  Especially  is  this  true  in  children  and  young  adults 
but  in  older  individuals,  where  there  is  considerable  chronic  adhesive 
inflammation  present  about  the  tonsil  and  where  the  arteries  are  some- 
what arteriosclerotic,  ligation  of  some  of  them  is  frequently  required, 
hence  the  thorough  knowledge  of  their  location  is  essential.  It  is  neces- 
sary to  retract  the  anterior  pillars  to  expose  to  view  the  exact  bleeding- 
points,  especially  those  of  the  recurrent  branch  of  the  lingual. 

The  pathological  conditions  of  faucial  tonsils  may  be  classified  into 
two  principle  tj^es: 


520  SURGERY  OF  THE  NOSE  AXD  THROAT 

A.  Hv-perplasia  of  the  l\iiiphoid  tissue  of  the  tonsil. 

B.  Infection  of  the  crypts  and  retention  with  secondary  infection 
and  inflammation  of  the  tonsil  and  peritonsillar  structures. 

The  former  change  is  usually  found  in  infancy  and  should  not  be 
very  much  interfered  with  surgically.  It  appears  to  be  a  normal 
response  on  the  part  of  the  hmphoid  ring  within  the  pharynx  to 
metabolic  processes  or  for  defense  against  infection. 

The  second  form  of  tonsillar  disease  is  where  we  find  the  greater 
variety  of  changes,  both  locally  as  well  as  distant  from  the  tonsils. 
Such  tonsils  may  be  large  or  small,  they  may  appear  red,  pus  or  caseous 
masses  may  or  may  not  be  expressed  from  them,  they  may  feel  hard 
or  soft  to  the  touch,  there  may  be  glandular  enlargment  within  the 
neck  and  they  may  cause  one  or  more  systemic  diseases,  usually  spoken 
of  as  a  chronic  septic  (focal)  infections. 

Locally  there  will  be  most  frequently  met  either  a  simple  follicular 
infection  or  peritonsillar  abscess.  Associated  with  this  infectious  ton- 
sillar disease  in  childhood  and  early  adolescent  life,  pathological  changes 
in  the  adenoid  tissue  of  the  epipharynx  will  also  be  found.  This  gives 
rise  to  an  additional  group  of  symptoms  that  are  most  important,  in 
the  life  of  the  individual.  Mouth  breathing,  repeated  infections  of  the 
upper  and  lower  respiratory  tract  including  the  middle  ear,  are  some  of 
the  commonest  complaints.  The  apparent  malnutrition  or  delayed 
development  both  mental  and  physical  are  well  known  and  believed 
today  to  be  due  to  chronic  foci  of  infection  in  the  adenoid.  In  the 
determination  of  the  presence  of  adenoids,  it  is  not  necessary  to  intro- 
duce the  finger  postnasally  which  is  only  an  additional  factor  in  spread- 
ing the  infection.  One  will  determine  whether  adenoids  are  present  at 
the  time  of  operation  on  the  tonsil.  The  writer  has  held  for  a  good 
many  years,  that  a  surgical  tonsil  is  also  a  surgical  adenoid,  and  vice 
versa.  Of  course  that  does  not  apply  to  the  hmphoid  hyperplasia  in 
the  infant  in  whom  it  is  often  necessary  to  remove  part  of  the  adenoids 
and  a  portion  of  the  tonsil  in  order  that  the  child  may  suck  the  nipple, 
or  drink.  It  frequently  occurs  that  associated  with  this  lymphoid  hvper- 
plasia,  there  is  repeated  infection  about  the  nose,  ears  or  bronchi :  and 
the  question  is,  should  such  a  child  be  subjected  to  a  radical  operation. 
The  writer's  practice  has  been  to  defer  such  radical  attacks  on  the  tonsils 
and  adenoids  until  the  child  is  three  years  of  age.  ^^^ly?  There  have 
been  observed  in  a  number  of  infants  operated  upon  radically  before 
the  age  of  three,  a  condition  not  unlike  mjocedema  wh'ch  gives  founda- 
tion for  the  belief  that  there  is  a  close  association  between  the  func- 
tions of  the  thjToid,  thjTnus  and  hmphoid  tissue  of  the  neck.  It  is 
•unnecessary  to  recapitulate  all  the  local  and  general  manifestations 
or  diseases  that  are  accredited  to  infectious  tonsils  and  adenoids;  how- 
ever, while  there  can  be  no  doubt  that  in  severe  and  chronic  con- 
ditions everyone  has  seen  most  striking  results  follow  a  thorough  ton- 
sillectomy and  adenectomy,  yet  there  is  no  doubt  that  the  operation 
has  been  too  zealously  overworked.     The  writer  is  referring  to  the 


THE  PHARYNX  521 

promiscuous  removal  of  tonsils  as  a  method  of  excluding  this  possible 
source  of  infection,  in  a  patient  complaining  of  indefinite  symptoms, 
before  the  physician  has  made  a  serious  effort  otherwise  to  arrive  at  a 
diagnosis.  Another  very  unwise  habit  is  that  of  minimizing  of  the  pos- 
sible dangers  from  a  tonsil  or  adenoid  operation. 

Treatment.— In  acute  conditions,  whether  primar\',  engrafted  or 
recurring,  exacerbations  should  always  be  treated  non-surgically  unless 
it  be  an  abscess  and  even  that  should  not  be  attacked  too  soon  in  its 
development. 

The  principles  in  the  treatment  of  acute  tonsillar  infection  are  rest 
to  the  parts  and  elimination  of  the  toxemia  resulting  from  the  infected 
tonsils  and  adenoids. 

The  less  the  amount  of  mechanical  treatment,  such  as  sprays  and  swabs, 
the  better;  because  these  methods  are  only  irritating  and  prolong  the 
process.  It  is  weU  known  that  gargles  do  not  reach  very  much  of  the 
tonsillar  area.  However,  a  mild,  warm  gargle  of  normal  saline  or  weak 
bicarbonate  of  soda  solution  has  a  tendency  to  relieve  the  pain  and  rid 
the  oropharynx  of  thick  secretions.  To  guard  against  complications 
in  the  middle  ear,  blood  and  kidney,  is  very  important;  and,  though 
not  apropos,  it  is  well  to  call  attention  to  the  importance  of  a 
correct  differential  diagnosis  between  acute  follicular  tonsillitis  and 
diphtheria. 

In  the  management  of  a  peritonsillar  abscess,  as  stated  before,  one 
should  wait  until  pus  has  actually  formed,  because  the  stabbing  into 
and  about  the  tonsil  is  both  painful  and  retards  recovery.  If  one 
should  see  the  case  in  the  very  beginning  he  may  prevent  the  abscess 
from  developing  by  gently  retracting  the  anterior  piUar  at  the  upper- 
most portion  of  the  tonsil  to  permit  the  escape  of  the  pent  up  infec- 
tion. Under  no  circuin stances  should  one  employ  probes  or  look  for 
the  seat  of  the  infection.  Once  the  abscess  is  formed  then  the  use  of 
hot  w^ater  in  the  mouth,  and  holding  it  there  until  it  has  cooled  is  very 
gratifying.  It  is  repeated  every  ten  minutes  for  one  hour  and  then  the 
patient  is  allowed  rest  for  one  hour.  This  heat  is  beneficial  both  for 
relieving  the  pain  and  hastening  suppuration.  The  place  where  one  will 
detect  fluctuation,  usually  about  the  third  day,  is  above  the  supra- 
tonsillar  fossa.  In  rare  instances  the  pus  formation  is  in  the  posterior 
pillar.  The  uvula  is  always  more  or  less  edematous  especially  when 
the  abscess  is  located  in  the  posterior  pillar.  To  open  the  abscess  one 
will  at  times  have  considerable  difficulty  in  inducing  the  patient  to  open 
the  mouth  wide  enough  to  get  at  its  site.  It  is  ver}^  painful  especially 
if  one  attempts  to  open  the  mouth  too  suddenly.  Five  or  ten  minutes 
should  be  consumed  in  that  procedure.  Then  apply  pure  flake  cocaine 
over  the  fluctuating  area,  to  be  incised.  By  means  of  a  curved  hj'po- 
dermic  needle;  the  mucous  membrane  is  next  injected  with  |  to  1  per 
cent,  procaine  or  apothesin.  Without  the  least  pain  an  ample  incision 
then  can  be  made  imtil  the  pus  is  reached.  With  the  aid  of  a  blunt 
pointed  artery  forceps,  the  opening  is  further  enlarged  and  the  pus 


522  SURGERY  OF  THE  NOSE  AND  THROAT 

evacuated,  ^"ery  seldom  does  tlie  abscess  recur  at  the  same  place,  but 
practically  always  the  patient  will  give  a  history  of  a  repetition  of  these 
abscesses,  usually  in  the  beginning  of  the  winter. 

Whether  the  process  is  recurrent  acute  follicular  tonsillitis  or  peri- 
tonsillar abscess,  the  indications  are  quite  clear  for  removal  of  the 
tonsils,  but  one  should  not  do  so,  until  all  the  acute  s^^Ilptoms  have  dis- 
appeared. This  usually  requires  from  ten  days  to  three  weeks.  It  is 
true  that  the  removal  is  very  much  easier,  the  sooner  one  operates  after 
an  acute  attack,  but  the  possibility  of  a  septic  process  in  the  throat, 
mouth  or  neck  which  has  been  reported  in  several  instances,  should 
keep  one  from  operating  too  early. 

The  treatment  of  chronic  tonsillar  disease  whether  causing  or  sup- 
posed to  cause  local,  regional  or  systemic  conditions,  requires  only  one 
kind  of  treatment,  and  that  is  a  thorough  operation,  known  as  tonsil- 
lectomy; and  if  adenoids  are  present  then  the  same  type  of  treatment 
should  be  simultaneously  addressed  to  that  structure.  AYhat  is  meant 
by  a  thorough  tonsiUectomy?  It  means  the  removal  of  the  entire 
tonsil  with  its  capsule  intact,  without  appreciable  destruction  or 
injury  of  neighboring  parts.  It  further  means  the  safeguarding  of 
the  patient  against  any  complications  such  as  accidents  from  anesthesia, 
hemorrhage,  sepsis  and  chemical  changes  in  the  blood  as,  for  instance, 
acidosis. 

As  to  the  technic  employed  it  does  not  make  much  difference.  As 
will  be  shown,  there  are  two  important  methods  in  vogue  at  present, 
both  of  which  have  their  advantages  and  disadvantages. 

The  two  methods  are: 

1.  Dissection. 

2.  Removal  by  one  instrument  without  preliminary  dissection, 
known  as  the  Sluder  ^lethod  or  one  of  its  many  modifications. 

Safeguarding  against  possible  complications  is  of  utmost  importance. 

I.  Accidents  from  Anesthetics. — The  operation  may  be  performed 
under  local  or  general  anesthesia.  In  children  and  many  nervous  and 
apprehensive  adults,  it  is  better  to  operate  under  general  anesthesia. 
The  great  advantage  in  saving  time  and  the  disagreeable  after-effects 
from  general  anesthesia,  make  the  operation  under  local,  topical  and 
infiltration  anesthesia,  a  great  favorite.  However,  several  of  the  tech- 
nical points,  for  instance,  ligating  vessels,  are  made  very  much  more 
difficult  under  local  anesthesia.  Ether  is  the  anesthetic  /^o''  excellence 
to  be  employed  although  nitrous  oxide  and  oxygen  furnish  a  valuable 
adjunct  in  the  induction  of  sleep.  The  use  of  morphin  before  opera- 
tion either  with  or  without  atropin  is  also  a  very  good  plan,  but  not 
as  a  routine,  because  there  are  people  who  know  that  morphin  does 
not  agree  with  them  and  it  should  not  be  used  in  such  cases.  It  is 
necessary  to  vaporize  the  ether  in  tonsil  and  adenoid  operation,  because 
the  work  is  performed  with  open  mouth  and  considerably  more  time 
is  required  for  the  anesthetic  than  is  safely  obtained  by  drop  or 
cone  method.     This  vapor  anesthesia  is  much  more  difficult  in  appli- 


The  pharynx  5^3 

cation  and  a  patient  will  very  frequently  go  into  a  deep  narcosis  with 
dilatation  of  the  pupils,  if  not  carefully  watched.  In  order  to  facilitate 
the  removal  of  secretion  and  blood  during  the  operation,  there  should 
always  be  at  hand  some  kind  of  apparatus,  in  the  form  of  vacuum  suc- 
tion that  will  take  care  of  them.  This  same  suction  process  acts  as  a 
sort  of  pulmotor  when  too  much  ether  has  been  inhaled.  The  writer 
is  of  the  opinion  that  this  suction  apparatus  is  in  a  measure  responsible 
for  the  non-occurrence  of  pneumonias  or  lung  abscesses  as  a  complica- 
tion to  tonsillectomies  under  general  anesthesia. 

The  control  of  the  bleeding  is  best  done  by  ligation.  It  is  perhaps 
difficult  for  some  to  ligate  deep  down  in  the  pharynx,  but  if  one 
will  make  it  a  practice,  it  will  soon  be  as  simple  as  other  ligations. 
Silk  is  the  material  employed  although  there  is  no  objection  to  catgut 
and  it  has  the  advantage  that  it  does  not  have  to  be  removed,  whereas 
silk  ligature  must  be  removed  at  times,  although  in  most  instances  it 
drops  off.  To  facilitate  ligation  the  writer  places  the  ligature  around 
an  artery  forceps  by  the  aid  of  a  needle,  tying  to  either  side  of  the 
forceps.  Great  care  should  be  exercised  in  picking  up  the  bleeding 
points  not  to  penetrate  the  fascia  with  the  forceps.  The  writer  picks 
up  these  vessels  with  an  Ellis'  pickup  forceps. 

General  sepsis  is  absolutely  excluded  in  tonsillectomies  and  the  writer 
can  only  refer  to  the  complication  from  hearsay  or  literature,  not  having 
encountered  a  single  case.  This  is  accounted  for  by  the  fact  that  a 
tonsillectomy  is  considered  a  major  operation  and  the  same  prepara- 
tion of  patients,  instruments,  etc.,  is  made  as  for  a  laparotomy.  Local 
infection  (saprophytic  and  posttraumatic)  always  occurs,  but  there  is 
very  little  difficulty  from  this  occurrence  and  it  passes  away  within  a 
week,  with  or  without  treatment.  lodin,  locally,  is  one  of  the  best 
measures  for  this  condition. 

Acidosis  does  not  occur  since  each  patient  receives  an  instillation 
of  30  to  60  grains  of  bicarbonate  of  soda  in  solution  per  rectum 
before  he  is  brought  to  the  operating-room.  Should  such  complication 
occur  then  an  intravenous  injection  of  bicarbonate  of  soda  or  glucose, 
of  each  30  grains  in  solution,  will  quickly  clear  up  the  condition.  It 
stands  to  reason  that  the  lungs  and  kidneys  are  always  carefully 
watched  after  operation,  but  the  writer  can  report  no  complication 
from  this  source. 

The  difficulty  with  local  anesthetics  is  that  neither  the  mental 
attitude  nor  the  muscular  reflexes  can  be  absolutely  controlled.  The 
effects  of  anesthetics  also  vary  in  different  individuals.  The  writer 
has  noted  that  the  men  who  use  a  great  deal  of  tobacco  react  or  gag 
very  much  more  than  those  who  use  it  moderately  or  not  at  all.  For- 
merly the  alcoholic  had  to  be  considered  in  the  same  class.  Certain 
races  are  more  reactive  and  sensitive  to  pain  than  others.  Russians 
and  Italians  are  practically  impossible  to  handle  under  local  anesthesia. 
The  local  application  of  pure  flaked  cocaine  to  the  entire  nose  and 
pharynx,  including  the  base  of  the  tongue,  will  go  a  long  way  toward 


524 


SURGERY  OF  THE  NOSE  AND  THROAT 


anesthetizing-  and  quieting  the  majority  of  the  patients'  throats,  for 
tonsillectomy.  The  infiltration  by  procaine  or  apothesin  is  not  carried 
out  until  just  before  the  removal  of  the  tonsil  from  the  deep  attach- 
ment, as  will  be  shown  in  the  technic. 

Technic. — Tonsil  and  adenoid  operations  under  general  anesthesia. 

Sluder's  Operation. — 1.  A  nitrous  oxide  anesthetsia  is  preferred. 

2.  After  the  patient  is  completely  anesthetized  (the  gag  having  been 
placed  in  the  mouth  before  the  gas  was  started),  the  mouth  is  opened 
wide,  the  tongue  depressed,  the  tonsil  is  lifted  out  of  its  fossa  by  means 
of  the  Sluder  guillotine  (Fig.  273)  and  drawn  forward  and  over  the 
molar  eminence  situated  on  the  inner  surface  of  the  inferior  maxillary 
bone  corresponding  to  the  second  molar  tooth. 

3.  Holding  the  tonsil  firmly  in  this  position  and  adding  pressure, 
the  tonsil  will  pass  through  the  fenestra  of  the  instrmnent. 


Fig.  273. 


Fig.  274. 


4.  To  aid  this  maneuver  the  thumb  or  finger  of  the  opposite  hand  is 
used  to  work  or  massage  the  tonsil  through  the  fenestra.  At  the 
same  time  the  semi-sharp  blade  of  the  instrument  is  driven  home  slowly, 
until  the  entire  tonsil  protrudes  on  the  mesial  side  of  the  instrument 
(Fig.  274). 

5.  By  the  aid  of  additional  pressure  from  an  arrangement  on  the 
handle,  the  attachments  of  the  tonsil  to  the  surrounding  structures  are 
severed  and  the  tonsil  removed  with  the  instrument. 

6.  In  many  instances  the  second  tonsil  is  removed  by  the  same 
technic  and  with  the  same  dose  of  gas,  but  usually  the  patient  is  re- 
anesthetized  and  then  the  second  tonsil  removed  in  the  same  manner. 

7.  The  bleeding  from  the  first  tonsillar  cavity  is  controlled  by 
pressure  sponges  on  holders.  After  the  second  tonsil  is  removed  and  the 
bleeding  controlled  by  pressure,  the  adenoids  are  removed. 

8.  The  patient  is  now  practically  awake  although  not  struggling. 
However,  if  that  should  take  place,  then  the  patient  is  anesthetized  for 
the  third  tiine.  The  removal  of  the  adenoids  is  performed  by  lifting 
the  patient  from  the  flat  position  to  a  semi-sitting  position  for  curettage 


THE  PHARYNX 


525 


with  an  adenoid  curette.  The  subsequent  bleeding  is  permitted  to 
cease  by  having  the  patient  turned  upon  his  face. 

Modification  of  Sluder's  Technic. — There  are  very  many,  but  none 
differ  from  the  original  principle  of  lifting  the  tonsil  from  its  bed  by  the 
instrument  and  pushing  it  through  the  fenestra  of  the  same. 

La  Force  Technic. — The  principal  change  lies  in  the  use  of  the  La  Force 
instrument  (Fig.  275).  It  is  an  apparatus  that  holds  down  the  dis- 
lodged tonsil  by  a  dull  blade,  to  produce  pressure  hemostasis  while  the 
tonsil  is  removed  or  severed  from  its  attaclmient  by  a  sharp  blade. 
The  object  is  to  minimize  the  bleeding. 


Fig.  275. — Hemostatic  tonsillectome,  La  Force's  latest  type.  This  instrument  is 
provided  with  a  hemostat  which  has  two  crushing  surfaces.  The  opening  is  almost 
square  in  wliich  the  tonsil  is  engaged  in  the  fenestra,  according  to  the  method  of  Dr. 
Greenfield  Sluder,  when  the  crushing  blade  is  forced  down  back  of  the  tonsil  and  all  the 
tissues  held  firmly  between  the  two  crushing  surfaces.  The  hemostat  is  allowed  to 
stay  in  place  from  five  to  ten  minutes  before  the  tonsil  is  cut  off  by  the  sharp  cutting 
blade  which  is  propelled  forward  by  the  smaller  of  the  two  wheels.  The  suture  device 
illustrated  here  is  not  now  attached  to  this  type  of  instrument,  but  may  be  added  if 
desired. 


Beck's  Technic  of  the  Modification  of  Sluder's  Operation. — The  writer 
recognized  very  early  in  the  history  of  the  Sluder  operation,  its  great 
value,  adapted  it  and  demonstrated  it  in  the  Cook  County  Hospital 
to  many  men,  chiefly  specialists.  He  also  very  early  recognized, 
what  to  him  were  difficulties.  In  order  to  overcome  them,  he  devised 
the  following  technic  as  fairly  well  outlined  in  the  paragraphs  on  safe- 
guards to  patient. 

1.  Patient  lies  fiat  on  the  table,  having  put  on  a  canvas  restraining 
jacket  (Figs.  276  to  278)  to  prevent  him  from  struggling  while  being 
put  asleep,  yet  not  interfering  with  respu'ation. 


526 


SURGERY  OF  THE  NOSE  AND  THROAT 


2.  Nitrous  oxide  and  oxygen  anesthesia  is  followed  by  drop  method 
of  ether  from  a  cone,  and  by  open  method  of  ether  vapor  anesthesia 
from  Beck-Mueller  apparatus  (Fig.  279). 

3.  Introduction  of  mouth  gag. 

4.  Two  small  rubber  urethral  catheters  passed  through  the  nostrils 
and  out  of  the  mouth;  loose  ends  held  by  a  small  clamp  (l^ig.  268). 

5.  Depress  the  tongue  and  by  means  of  Beck's  tonsillectome  (Fig. 
280)  lift  the  tonsil  from  its  bed  into  the  supratonsillar  fossa.  Care 
should  be  exercised  to  get  the  lower  pole  of  the  tonsil  well  engaged  into 
the  ring  of  the  instrument  when  dislodging  the  tonsil  upward. 


Fig.  276 


Fig.  277 


6.  Without  the  least  change  in  the  position  of  the  tonsillectome,  the 
finger  of  the  opposite  hand  feels  the  dislodged  tonsil  in  the  supratonsillar 
space,  and  begins  to  make  firm  pressure  over  the  round  eminence, 
while  holding  the  tonsillectome  equally  firm.  In  the  majority  of  cases, 
especially  in  children,  the  tonsil  will  be  dislodged  through  the  fenestra 
without  great  effort,  but  in  some  cases  more  persistent  effort  is  neces- 
sary before  all  the  adhesions  give  way  and  the  capsule  of  the  tonsil 
turns  upon  itself.  Great  caution  must  be  exercised  at  the  time  of 
pushing  the  tonsil  through  the  ring,  not  to  use  the  fingernail,  otherwise 


THE  PHARYNX  527 

trauma  or  even  perforation  of  the  anterior  pillar  may  result.  Also 
in  holding  the  tonsillectome  in  its  supratonsillar  position  it  must  never 
be  permitted  to  slide  about,  but  should  be  held  in  one  position  right 
against  the  dislodged  tonsil. 

7.  The  tonsil  having  been  dislodged  by  the  index  finger  one  will  feel 
the  margins  of  the  ring,  while  holding  the  finger  to  guard  against  the 
tonsil  slipping  back,  the  thumb  of  the  same  hand  or  the  assistant 
releases  the  lock  of  the  snare  and  the  same  is  drawn  down  until  con- 
siderable resistance  is  felt.     Then  the  snare  is  locked  again. 


Fig.  278 
Figs.  276,  277  and  278. — Beck-Hanson's  restraining  jacket. 

8.  One  can  now  see  the  tonsil  protruding  mesially  (Fig.  281),  while 
at  the  anterior  pillar  is  seen  a  retraction  corresponding  to  the  tonsillar 
capsule  turned  upon  itself  which  indicates  a  successful  enucleation. 

9.  Drive  into  the  protruding  tonsil  the  Lewis  double  screw  (Fig.  282) 
to  keep  it  from  dropping  into  the  throat  when  it  is  raised. 

10.  Turn  the  thumb  ring  of  the  tonsillectome  from  right  to  left. 


528 


SURGERY  OF  THE  NOSE  AND  THROAT 


which  turns  the  screw  shaft  of  the  snare  as  the  wire  is  cutting  off  the 
attachment  of  the  tonsil  to  the  surrounding  structures. 


Fig.  279. — The  Beck-Mueller  ether-vapor  and  vacuum  apparatus.  This  apparatus 
is  the  result  of  several  years  of  experimentation,  having  been  placed  on  the  market 
only  after  its  practicability  had  been  thoroughly  demonstrated.  Ether-vapor,  properly 
warmed,  has  been  extensively  used  for  some  years;  advantages  of  ether-vapor  in  prefer- 
ence to  the  drop  method  of  anesthesia  being  generally  conceded.  The  foot  or  hand 
pump,  however,  has  made  this  a  rather  inconvenient  method,  requiring  too  much 
of  the  anesthetist's  attention.  Aspirating  blood  or  mucus  means  a  very  considerable 
saving  of  time  and  gives  the  operator  a  clear  field.  The  Beck-Mueller  apparatus  com- 
bines these  two  principles.  The  motor  of  special  design  by  direct  connection  drives 
two  pumps,  one  for  pressure  and  one  for  vacuum.  The  air  under  pressure  is  sent  to 
the  ether  bottle,  where  the  ether-vapor  is  formed.  Especially  designed  electrical 
heating  units  keep  the  ether  from  becoming  too  cold  and  also  warm  the  ether-vapor 
just  before  it  is  sent  to  the  patient.  A  filter  absorbs  any  dust  particles  or  other  foreign 
materials,  thus  producing  a  suitable  warm  ether  vapor  continuously  delivered  at  a 
low  pressure.     The  vacuum  pump  creates  a  constant  vacuum  within  the  bottle. 


THE  PHARYNX 


529 


11.  The  anesthetist  grasps  and  pulls  the  rubber  catheter  on  the  side 
corresponding  to  the  tonsil  that  was  removed,  and  draws  the  soft 


ex. 


0"^  C.-L 

Fig.  280. — Beck's  tonsil  snare. 


Fig.  281. 


azmsinTTs-s 


Fig.  282. — Lewis's  double  screw. 


palate  forward,  thus  bringing  the  anterior  and  posteriorjpillars  in 
apposition  and  obliterating  the  tonsillar  camtx,  holding  thejbleeding 


VOL.  1—34 


530 


SURGERY  OF  THE  XOSE  AXD  THROAT 


for  a  time.     Pressure  of  this  traction  also  compresses  the  upper  blood 
supply. 

12.  The  escaped  blood  and  secretions  are  sucked  up  and  a  small 
gauze  sponge  on  an  Ellis  pickup  forceps  is  put  into  the  formed  pocket 
of  the  anterior  and  posterior  pillars,  by  the  traction  on  the  catheter. 

13.  The  same  technic  is  carried  out  on  the  opposite  side,  only  chang- 
ing from  one  hand  to  the  other.  The  same  management  of  the  ton- 
sillar cavity  as  in  the  first  instance. 


Fig.  283. — Stevenson's  adenotome. 

14.  Both  catheters  are  now  drawn  over  the  face  of  the  patient,  and 
if  there  is  no  very  active  bleeding  from  either  tonsillar  cavity,  the 
adenoids  are  removed.  This  is  accomplished  by  the  aid  of  the  Steven- 
son modification  of  La  Force  adenotome  (Fig.  283).  Only  a  part  of 
the  adenoid  is  removed  with  this  instrument,  the  remains  of  the  tissue 
being  removed  by  the  adenoid  curette.  While  this  slow  and  light 
pressure  removal  of  the  adenoids  by  the  curette  is  going  on  the  assistant 
has  the  suction  tube  in  the  oro-  and  hypopharynx  to  prevent  any 
blood  being  aspirated. 

15.  Should  there  be  any  evidence  of  adenoids  laterally  in  the  region 
of  the  Eustachian  orifice  or  on  the  posterior  surface  of  the  posterior 
pillars,  then  the  dull  ring  curette  (Fig.  284)  is  made  use  of. 


Fig.  284.- — Maier's  dull  ring  ciirette. 

16.  Having  completed  the  removal  of  the  adenoids  a  strip  of  gauze, 
folded  four  times,  and  one-half  inch  wide  and  six  to  ten  inches  long, 
is  packed  into  the  postnasal  space,  the  catheters  relaxed  so  that  the 
soft  palate  holds  that  strip  in  place.  This  entirely  controls  the 
bleeding. 

17.  The  tonsillar  fossre  are  now  inspected  for  bleeding  and  if  there 
be  any,  each  bleeding  point  is  picked  up  and  ligated.  As  mentioned 
in  the  paragraph  on  safeguard  of  patient,  retraction  of  anterior  pillars 
is  often  necessary  to  find  the  bleeding  point.     This  is  best  done  by 


THE  PHARYNX  531 

retractors  (Fig.  285).     The  most  troublesome  bleeding  usually  occurs 
low  down  in  the  tonsillar  fossa. 

18.  When  all  bleeding  in  the  tonsillar  fossae  is  controlled  the  catheters 
are  once  more  drawn  forward,  the  folded  gauze  strip  removed  and  the 
postnasal  space  inspected.  Should  oozing  start  anew,  with  one  or 
two  curved  artery  forceps  the  surgeon  can  grasp  the  median  region 
of  the  posterior  vault  which  invariably  controls  the  bleeding  after  a 
few  moments. 

19.  The  patient  is  returned  to  his  room  with  the  face  turned  down, 
lying  on  his  stomach  with  a  pillow  under  his  chest  so  as  to  make  the 
throat  much  lower  than  his  chest. 


Dissectioii|Method.^ — Until  Sluder  presented  his  method  of  tonsillar 
removal,  the  dissection  method  was  considered  the  only  ideal  operation, 
for  the  removal  of  tonsils.  It  was  with  considerable  reluctance  that 
the  majority  of  operators  even  gave  consideration  to  the  technic 
introduced  by  Sluder.  Had  it  not  been  the  for  fact  that  Sluder  was 
a  recognized  authority  on  rhinolaryngological  subjects,  the  writer  is 
convinced  it  would  have  taken  much  longer  before  such  a  departure 
from  the  well-established  dissection  operation  would  have  been  adopted. 
Even  today  there  are  many  operators  dissecting  tonsils  and  it  is  a  good 
thing  that  every  one  knows  the  dissection  operation,  especially  the 
young  or  less  experienced.  The  reason  for  this  is  that  should  one  fail 
with  the  single  instrimient  operation,  he  has  always  recourse  to  the 
dissection  method. 

Technic. — 1.  Up  to  the  point  of  employing  the  single  instrument 
(guillotine  or  snare),  whether  under  local  or  general  anesthesia,  the 
technic  is  the  same. 

2.  Drive  the  Lewis  double  screw  (Fig.  282)  into  the  substance  of 
the  tonsil  near  its  upper  pole  and  draw  it  toward  the  median  line  and 
somewhat  downward.  This  brings  the  anterior  pillar  on  the  stretch  at 
the  attachment  of  the  tonsil. 

3.  Allowing  a  thin  collar  of  the  margin  of  the  mucous  membrane  of 
the  anterior  pillar  attached  to  the  tonsil,  a  semicurvilinear  incision  is 
made  down  to  the  capsule  by  means  of  knife  (Fig.  286).  Great  care 
should  be  taken  there,  not  to  penetrate  the  capsule  (Fig.  287). 

4.  By  the  aid  of  the  long-handled,  cm"ved  Mayo  scissors  the  incision 
is  enlarged  both  downward  to  the  anterior  pillar  and  over  the  supra- 
tonsillar  region  to  the  posterior  pillar. 


532 


SURGERY  OF  THE  NOSE  AND  THROAT 


5.  Pulling  more  firmly  on  the  double  screw  tenaculum  the  head  of 
the  tonsil  is  dislodged  and  the  remaining  loose  attachment  brought  on 
a  stretch  (Fig.  288). 

6.  With  the  same  scissors  these  attachments  of  the  tonsils  are 
severed  especially  low  down  anteriorly  at  the  plica  triangularis  and 
posteriorily  from  the  posterior  pillar. 


Fig.  286.— Beck's  knife. 

7.  Removing  the  double  screw  tenaculum  from  the  upper  dissected 
pole  and  driving  it  into  the  lower  half  for  the  purpose  of  better  engage- 
ment into  the  snare  or  for  complete  dissection  without  the  snare. 

8.  Passing  the  tonsillectome  (Fig.  280)  over  the  tenaculum  and 
drawing  the  dissected  portion  of  the  tonsil  through  the  ring  the  lowest 
portion  of  the  tonsil  is  further  lifted  into  the  ring,  the  wire  released  and 
drawn  down. 


Fig.  287. —  1,  incision;  2,  Lewis's  screw. 


Fig.  288.— 1,  capsule. 


9.  Inject  by  means  of  a  hypodermic  about  fifteen  minims  of  ^  to  1 
per  cent,  procaine  or  apothesin  solution  into  and  external  to  the  mass 
held  by  the  snare. 

10.  Turn  the  thumb  ring  from  right  to  left  until  the  remains  of  the 
tonsillar  attachment  is  severed. 

11.  Instead  of  employing  the  snare,  one  may  complete  the  removal 
of  the  lowest  portion  of  the  tonsil  by  means  of  the  scissors.  This  is 
less  painful  and  more  certain  to  get  this  mass  of  hypertrophic  lymphoid 
tissue  mentioned  in  the  surgical  anatomy,  which  so  often  undergoes 
compensatory  hypertrophy  and  makes  it  appear  as  though  the  opera- 
tion had  not  been  properly  done. 

12.  The  management  of  the  bleeding,  etc.,  is  the  same  as  when  the 
single  instrument  is  employed. 


THE  PHARYNX 


533 


13.  Should  the  bleeding  persist  as  a  general  oozing  or  start  up 
secondarily,  then  the  introduction  of  a  piece  of  gauze  saturated  in 
tincture  of  benzoin  is  placed  between  the  anterior  and  posterior  walls 
and  sutured  there  for  twelve  hours  (Fig.  289). 


Fig.  289. 


14.  If  in  spite  of  these  efforts  the  bleeding  still  continues  then  one 
must  resort  to  the  tonsil  clamp  (Fig.  290)  which  invariably  controls 
the  bleeding,  but  its  retention  is  quite  painful.  Great  care  must  be 
exercised  not  to  use  too  much  and  too  long  a  pressure,  otherwise  one 
may  have  a  complication  of  necrosis  or  sloughing. 


Fig.  290. — Beck's  tonsil  clamp. 


In  conclusion  I  wish  to  acknowledge  the  liberal  way  in  which  I  have 
used  the  illustrations  from  Loeb's  Text-book  on  Operative  Surgery  of  the 
Nose,  Throat  and  Ear,  which  were  modified  by  Mr.  A.  B.  Streedain. 


SURCtERY  of  the  3I0UTH  A^J)  FACE. 


By  GEORGE  VAN  INGEN  BROWN,  D.D.S.,  M.D.,  F.A.C.S. 

DENTO-ALVEOLAR  ABSCESS. 

Dento-alveolar   abscess   is   an   accumulation   of   pus   surrounding 
or  associated  with  the  apical  end  of  the  root  of  a  devitalized  tooth 

(Fig.  291). 


Fig.  291. — Alveolar  abscessed  teeth  showing  granulomatous  and  other  ill  effects  of 
dento-alveolar  abscess  upon  the  roots  of  teeth  and  the  hopelessness  of  endeavoring  to 
save  roots  of  this  character.     (Latham.) 

Pericemental  abscesses  occur  in  connection  with  the  roots  of  teeth 
having  vital  pulps. 

(535) 


536  SURGERY  OF  THE  MOUTH  AXD  FACE 

Etiology. — A  tooth  pulp  may  become  devitalized  through  its  exposure 
in  the  course  of  dental  caries  whereby  it  is  subjected  to  irritation  by 
the  secretions  of  the  mouth,  bacterial  invasion  and  other  vicious 
influences.  Severe  traumatic  injury  may  destroy  the  integrity  of  the 
bloodvessels  and  nerves  as  they  enter  the  apical  foramen  and  thus 
cause  loss  of  vitality  in  tooth  pulps.  This  may  also  occur  from  severe 
pericemental  inflammation  or  infection  in  this  region.  Devitalized 
pulps  usually  become  gangrenous.  Sulphide  of  hydrogen  and  ammonia 
are  thus  formed  in  conjunction  with  ptomains  and  pyogenic  micro- 
organisms. Septic  agents  are  then  forced  through  the  apical  foramen 
by  the  confined  gases  within  the  pulp  chamber  of  the  tooth  and  thus 
infection  of  the  alveolar  structures  surrounding  the  apex  of  the  root 
results  in  due  course  in  the  formation  of  a  typical  abscess  at  that  point. 
This  may  extend  until  the  pus  finds  an  exit  through  a  fistulous  opening 
into  the  mouth,  or  failing  this  becomes  what  is  known  as  a  blind 
abscess,  or  the  pus  may  find  its  way  through  channels  of  bone  until 
it  reaches  some  more  distant  point  of  exit  such  as  the  maxillary  sinus 
or  the  nasal  cavity.  It  is  the  so-called  blind  abscesses  that  offer  the 
greatest  opportunity  for  the  continuation  of  bacteria  in  these  foci  of 
infection  for  long  periods  of  time  without  creating  noticeable  dis- 
turbance. Focal  infection  of  this  character  has  recently  become  a 
matter  of  much  serious  consideration  in  the  treatment  of  disease. 
When  the  pulps  of  teeth  are  destroyed  in  the  course  of  dental  operations 
the  complete  extirpation  of  the  pulp  tissue  from  the  root  canal  is 
required,  and  the  pulp  chamber  must  be  completely  filled  to  the  apex 
of  the  root  with  some  suitable  material.  This  often  is  imperfectly 
done,  and  on  account  of  innumerable  small,  tortuous,  or  otherwise 
defectively  formed  root  canals,  it  is  frequently  impossible  to  accomplish 
the  complete  cleansing  of  such  roots.  Under  such  circumstances  there 
is  always  likelihood  of  the  occurrence  of  infection  at  the  unfilled  end  of 
the  root.  In  this  way  large  numbers  of  dento-aheolar  abscesses  have 
occurred,  the  existence  of  which  has  not  been  suspected,  and  these  are 
now  understood  to  have  been  the  cause  of  grave  results  as  factors  in 
creating  pathologic  disturbance  (Figs.  292  to  295). 

Bacteriological  examinations  of  abscesses  in  connection  with  the 
roots  of  teeth  by  Rosenow,^  Gilmer  and  INIoody,-  Hartzell  and  Henrici^ 
show  that  in  a  varied  flora  the  streptococci  were  found  to  be  the  most 
constant  microorganisms. 

The  streptococcus  viridans  group  is  found  almost  universally  present 
in  alveolar  abscesses  and  suppurative  inflammations  involving  the 
pericemental  and  surrounding  structures. 

Pathology. — Kosenow  describes  the  pathological  significance  oj  dento- 
aheolar  abscesses  as  foci  of  infection  in  the  following  manner: 

1  Chicago,  Illinois.  * 

^  A  Study  of  the  Bacteriology  of  Alveolar  Abscess  and  Infected  Canals,  Jour.  Am. 
Med.  Assn.,  December  5,  1915,  p.  202.3. 

'  A  Studj-  of  Streptococci  from  Pyorrhea  Alveolaris  and  from  Apical  Abscesses,  Jour. 
Am.  Med.  Assn.,  March  27,  p.  1055. 


DENTO-ALVEOLAR  ABSCESS 


537 


"The  affinity  for  joints,  endocardium,  pericardium,  and  often  also 
myocardium  and  muscles,  which  characterizes  streptococci  when  first 
isolated,  tends  to  disappear  on  cultivation.  It  may  be  restored  by 
animal  passage  and  other  strains  of  streptococci;  under  certain  con- 
ditions it  may  be  made  to  acquire  the  features  of  the  strains  from 


Fig.  292  Fig.  293 

Fig.  292. — Dento-alveolar  abscess  associated  with   anemia. 

Fig.  293. — Defective  root  fillings  from  the  mouth  of  a  business  man  with  extensive 
interests,  who  broke  down  so  completely  that  he  was  obliged  to  give  up  work  and  with- 
draw from  active  participation  in  the  direction  of  the  institutions  with  which  he  was 
connected.  Travel  abroad,  trips  to  Carlsbad  and  other  watering  places,  with  consulta- 
tion by  prominent  internists  in  this  country  and  Europe  gave  no  relief  and  no  definite 
diagnosis.  Urinalyses  and  blood  examinations  gave  every  evidence  of  diseased  condi- 
tions, but  no  light  as  to  the  cause.  Complete  recovery  followed  the  treatment  and 
extraction  of  several  diseased  teeth. 

rheumatism.  When  the  rheumatic  strains  have  acquired  the  cultural 
features  of  hemolytic  streptococci  they  lose  the  affinity  for  endocardium 
and  pericardium  and  acquire  an  even  greater  affinity  for  the  joints. 
When  they  have  been  converted  into  pneumococci  of  a  certain  grade 
of  virulence  pulmonary  hemorrhages  and  pneumonia  are   commonly 


Fig.  294  Fig.  295 

Fig.   294. — ^Large   dento-alveolar   abscess  associated  with   a   devitalized   gangrenous 

pulp  in  the  lateral  incisor,  the  root  of  which  was  not  filled,  and  imperfectly  filled  root 

canals  in  the  first  bicuspid  and  central  incisor  teeth.     In  this  case  the  maxillary  sinus 

was  also  involved. 

Fig.  295. — Dento-alveolar  abscess  and    bone  destruction  due  to  pyorrhea  alveolaris. 

The  maxillary  sinus  was  involved  in  this  case. 


found  after  intravenous  injections,  whereas  when  the  virulence  is  still 
greater,  death  from  pneumococcemia  results.  These  and  other  facts 
suggested  strongly  the  possibility  that  previous  to  an  attack  of 
rheumatism  various  types  of  the  streptococcus  group,  especially  hemo- 
lytic streptococci,  acquire  in  the  tissues  of  the  infected  individual  the 


538  SURGERY  OF  THE  MOUTH  AND  FACE 

features  which  give  them  the  simultaneous  affinity  for  joints,  endo- 
cardium, pericardium  and  myocardium. 

"The  places  in  the  human  body  where  such  conditions  prevail  and 
where  special  features  are  likely  to  be  acquired  are  parts  of  infection 
such  as  in  the  tonsils,  various  sinuses,  the  appendix  and  about  the 
gums  and  teeth.  The  importance  of  focal  infections,  as  a  point  of 
entrance  of  bacteria  in  general  is  quite  well  recognized,  but  the  idea 
that  the  focus  serves  in  addition  as  a  place  where  bacteria  can  acquire 
new  properties  is  not  generally  recognized  and  needs  to  be  emphasized. 

"The  strains  from  muscular  rheumatism,  especially  after  one  or 
two  animal  passages,  as  well  as  other  streptococci  when  they  have 
attained  a  similar  grade  of  virulence,  show  a  marked  affinity  for  the 
mucous  membrane  of  the  stomach,  the  pelvic  mucous  membrane  and 
medullary  portion  of  the  kidney  and  the  gall-bladder.  Ulcer  of  the 
stomach,  the  picture  of  an  ascending  nephritis,  cholecystitis  with 
beginning  formation  of  gall-stones,  caused  by  streptococci,  have  been 
found  repeatedly  in  rabbits  and  dogs  injected  with  these  strains, 
especially  after  one  or  more  animal  passages." 

These  conclusions  have  not  been  universally  accepted.  Howe  and 
other  writers  do  not  believe  they  have  been  conclusively  proved, 
nevertheless  the  work  of  Rosenow  has  been  corroborated  by  some 
investigators  and  much  evidence  has  been  developed  in  the  study  of 
clinical  cases  that  serves  to  emphasize  the  importance  of  these  findings. 
It  is  therefore  no  longer  a  matter  which  occasions  surprise  when  an 
important  relationship  is  found  to  exist  between  foci  of  infection  in 
connection  with  diseased  teeth  and  cases  of  rheumatoid  arthritis, 
iritis,  endocarditis,  myocarditis,  ulcer  of  the  stomach,  disease  of  the 
kidneys,  or  anemia,  leukemia  and  other  affections  manifesting  them- 
selves through  blood  disturbances;  chorea,  and  many  similar  disorders 
of  almost  unlimited  extent  or  pathological  manifestations  touching 
the  brain,  spinal  cord  and  nerve  structures  in  which  infection  may 
play  a  part. 

Treatment.— Much  confusion  exists  at  the  present  time  between 
dentists  in  their  desire  to  save  teeth,  and  physicians  and  surgeons,  whose 
chief  interest  lies  in  relieving  the  aflfections  from  which  their  patients 
may  be  suffering  without  regard  to  the  possible  value  of  teeth  that  may 
be  sacrificed.  The  extreme  positions  in  this  regard  are  represented  by 
the  dangerous  practice  of  retaining  diseased  roots  in  the  mouth  which 
may  continue  to  act  as  foci  of  infection  with  disastrous  results,  and  the 
indiscriminate  extraction  of  every  tooth  which  may  not  be  absolutely 
sound,  in  the  more  or  less  bUnd  hope  that  some  not  fully  understood 
disease  may  thus  be  relieved. 

Rosenow  and  others  incline  to  the  belief  that  once  a  tooth  pulp 
becomes  devitalized  such  a  root  is  always  a  menace  regardless  of  the 
care  with  which  the  pulp  may  be  extracted  and  the  root  canal  filled. 
This  opinion  is  based  upon  the  fact  that  a  tooth  root  contains  not  only 
the  contents  of  its  pulp  canal  including  the  bloodvessels,  nerves, 
connective  tissue,  etc.,  but  dentinal  tubuli  also.     Since  these  tubuli 


PLATE   VI 


Fig.   1 


Illustration  of  a  Seetioii  of  a  Tooth  with  the  Dental  Tubuli 
Stained  hy  Injection  of  the  Tooth  Pulp.  A  Rare  Result 
Accomplished  by  Dr.  V.  A.   Latham,  of  Chicago. 


Fig.   2 


Illustration  of  a  Section  of  a  Tooth  with  the  Dentinal 
Tul-juli  Stained  by  Injection  of  the  Dental  Pulp.  It  also  Shows 
the  Result  of  a  Pericemental  Abscess.     (Dr.    V.  A.   Lathani.) 


PLATE    VII 


Dentin  Impregnated  with  Rosin-ehloropereha  Solution. 

(CalJahan.) 


DENTO-ALVEOLAR  ABSCESS 


539 


extend  tliroughout  the  dentinal  structures  of  the  root  itself,  their 
vital  contents  when  deprived  of  the  nourishment  of  a  living  tooth 
pulp  may  become  disorganized  and  thus  become  foci  of  infection. 
(See  Plate  YI.)  To  meet  this  situation,  Callahan  of  Cincinnati  has 
added  to  the  usual  gutta  percha  point  and  gutta  chlora  percha  (gutta 
percha  dissolved  in  chloroform)  rootfiUing,  a  preparation  of  rosin  which 
he  has  demonstrated  can  be  made  to  permeate  and  seal  these  dental 
tubuH.    (See  Plate  VII.) 

This  would  seem  to  reheve  doubt  in  that  respect  and  should  be 
insisted  upon  when  medical  practitioners  are  interested  in  the  direction 
of  the  treatment  of  the  roots  of  such  teeth  for  their  patients  in  impor- 
tant cases.  The  question  of  the  possibility  of  the  cure  of  dento-alveolar 
abscesses  in  such  manner  as  to  make  it  entirely  safe  to  leave  the  affected 
root  in  situ  when  there  is  a  suspicion  of  the  pernicious  influence  of  such 
foci  of  infection  is  a  matter  of  much  more  difficult  decision  than  the 


Fig.  296  Fig.  297 

Fig.  296. — Radiogram  showing  the  result  of  a  dento-alveolar  abscess.  In  this  case 
there  -was  an  acute  arthritic  affection  of  the  left  shoulder^  severe  long  continued  head- 
ache and  progressive  loss  of  %"ision.  All  these  sjTnptoms  were  relieved  after  surgical 
treatment  of  the  diseased  area,  and  proper  filling  of  the  root  canals  of  the  afiected  teeth. 
Fig.  297. — Radiogram  taken  approximately  one  j"ear  after  the  one  shown  in  Fig.  296 
fcr  the  same  patient.    Bone  regeneration  in  the  diseased  area  is  evident. 

treatment  of  uninfected  root  canals.  The  surgical  removal  of  such 
abscesses  including  the  pyogenic  membrane  of  the  abscess  sac  and  the 
surrounding  alveolar  bone  structtires  may  sometimes  be  successfully 
accomplished  with  complete  relief  of  the  affection  apparently  caused  by 
such  foci  of  infection  and  without  loss  of  the  teeth.  Examples  of  this 
treatment  are  shown  in  Figs.  296  and  297).  That  this  cannot  always 
be  accomplished  with  safety,  is  clearly  sho"^m  by  the  illustrations  of 
other  cases  in  Figs.  292  to  295.  Amputation  of  the  apical  portion  of 
the  root  area  that  has  been  denuded  of  its  pericementum  and  removing 
it  T\'ith  the  diseased  bone  is  occasionally  successful  in  completely 
eradicating  the  diseased  conditions  when  not  more  than  one-third  of 
the  pericemental  tissue  has  been  lost. 

For  the  guidance  of  physicians  and  stirgeons  the  following  rules  of 
procedure  would  seem  to  be  ad\'isable. 

1.  It  must  be  admitted  that  the  value  of  a  tooth  or  teeth  cannot  be 
allowed  to  weigh  in  the  balance  against  the  reasonable  possibility  of 


540  SURGERY  OF  THE  MOUTH  AND  FACE 

relieving  serious  general  affections.  Extraction  should  therefore  be 
insisted  upon  unless  complete  security  in  this  respect  can  be  given  by 
the  treatment  of  the  roots  of  such  teeth. 

2.  If  an  attempt  be  made  to  treat  the  root  canals  of  suspicious  teeth 
under  these  circumstances  the  sealing  of  the  tubuli  according  to  the 
Callahan,  or  some  similar  method  should  be  insisted  upon. 

3.  There  should  not  only  be  radiograms  to  show  the  condition  before 
treatment  but  immediately  after  also  to  prove  that  the  root  filling  has 
reached  the  apical  end  of  the  root.  If  the  root  canal  filling  is  imperfect 
it  should  be  made  perfect  or  the  tooth  extracted. 

4.  After  a  sufl5cient  interval  has  elapsed  another  radiogram  should 
be  taken  if  necessary  to  demonstrate  beyond  the  question  of  a  doubt 
that  there  has  been  complete  regeneration  of  the  bone  and  pericemental 
structures  surrounding  the  end  of  the  root,  with  total  obliteration  of  the 
abscess.  With  such  care  many  teeth  could  undoubtedly  be  saved  with 
safety.  Without  such  precaution  the  only  safe  procedure  is  to  extract 
the  teeth  in  order  to  remove  the  risk  of  continuation  of  the  disease. 

5.  It  must  not  be  forgotten  that,  in  many  instances,  the  indiscrimi- 
nate extraction  of  teeth  to  relieve  remote  affections  in  the  absence  of 
complete  diagnosis  for  the  exclusion  of  other  causes  is  a  doubtful 
endeavor  to  relieve  present  ills  with  almost  certain  invitation  of  future 
disturbance.  The  extraction  of  even  one  tooth  from  a  perfect  dental 
arch,  paves  the  way  for  malocclusion  which  may  lead  to  pyorrhea 
alveolaris  or  some  similar  affection  in  the  future.  The  loss  of  a  number 
of  teeth  destroys  the  functional  activity  of  the  jaws  and  may  make 
itself  felt  in  the  disarrangement  of  the  digestive  tract  at  some  later 
period.  Moreover  the  efi'ect  upon  metabolism  of  proper  or  improper 
mastication  of  food  is  one  that  cannot  lightly  be  overlooked. 

With  the  foregoing  rules  for  guidance,  much  may  be  done  with  safety 
for  the  simultaneous  relief  of  focal  infections  and  tooth  preservation. 

MOUTH  EXAMINATION  WITH  REFERENCE  TO  FOCAL 
INFECTION. 

.  Under  artificial  tooth  crowns  and  bridges  and  above  and  below  the 
roots  of  teeth  that  have  been  treated  for  long  periods  dento-alveolar 
abscesses,  bone  cysts  or  other  sources  of  pus  formation  are  matters  of 
frequent  occurrence.  They  may  discharge  through  fistulse  and  thus 
permit  the  microorganisms  to  meet  the  antagonistic  agencies  commonly 
contained  in  the  buccal  secretions,  but  quite  often  they  find  their  way 
more  or  less  directly  into  the  bone  circulation,  and  thus,  without  any 
neutralizing  safeguard,  perhaps  with  opportunity  to  gain  increased 
virulence,  as  suggested  by  Rosenow,  they  assume  a  much  more  serious 
role  than  is  usually  appreciated. 

These  are  the  factors  it  is  difficult  to  uncover,  and  they  exist  where 
least  looked  for. 

The  following  suggestions,  although  by  no  means  intended  to  be 
complete,  will  be  useful  for  general  practitioners  of  medicine  and 


MOUTH  EXAMINATION  AND  FOCAL  INFECTION  541 

surgery  to  enable  them  in  the  course  of  more  or  less  cursory  examina- 
tions, such  as  would  be  practicable  in  an  office  examination,  to  at  least 
determine  the  likelihood  of  the  existence  of  pathogenic  influences  in 
the  mouths  of  patients. 

1.  Note  the  general  appearance  of  the  teeth;  the  color  and  appear- 
ance of  the  mucous  membrane  of  the  mouth;  and  evidences  of  daily 
care,  etc.  Observe  if  the  gums  are  inflamed;  if  there  be  discharge  of 
pus  about  the  necks  of  the  teeth  on  pressure;  if  any  of  the  teeth  have 
been  lost;  and  inquire  if  the  patient  has  ever  received  treatment  for 
pyorrhea  alveolaris. 

2.*  Make  sure  of  the  presence  of  the  full  number  of  teeth  in  the 
mouth  according  to  the  age  of  the  individual,  and  endeavor  to  have 
missing  teeth,  if  any,  accounted  for. 

3.  Examine  carefully,  with  a  small  electric  light  in  the  mouth  if 
possible  or  in  strong  sun  light,  the  color  of  each  tooth  when  compared 
with  adjoining  teeth.  Vital  teeth  with  living  pulps  are  easily  recognized 
by  being  more  translucent  than  those  in  which  the  pulps  have  been 
destroyed.  While  teeth  with  living  pulps  may  cause  painful  and  other 
nervous  affections  they  are  not  likely  to  affect  the  vitality  of  the 
individual.  If  the  crown  of  the  discolored  tooth  has  no  carious  cavity 
and  has  not  been  filled,  inquiry  should  be  made  for  a  history  of  previous 
traumatic  injury.  The  faradic  current  gives  positive  distinction 
between  teeth  with  living  pulps  and  those  in  which  the  pulps  have 
become  devitalized. 

Teeth  that  have  large  carious  cavities  or  diseased  roots  which 
discharge  through  fistulse  upon  the  gum  surface  are  easily  discovered. 
Over  and  over  again  the  author  has  found  most  serious  and  long- 
continued  results  from  teeth  that  had  no  carious  cavities  and  bore  no 
outward  evidence  of  being  affected  by  any  unusual  condition  except 
a  more  or  less  dark  appearance  when  compared  with  adjoining  teeth. 
Upon  inquiry  in  these  cases  it  has  sometimes  been  found  that  there  was 
a  history  of  a  fall  some  years  before  or  a  jar,  which  jammed  the  teeth 
tight  together,  or  a  traumatic  injury  of  some  sort,  which,  although 
it  may  have  caused  only  temporary  discomfort,  yet  was  sufficient  to 
injure  the  little  nerve  filaments  that  form  the  connection  between  the 
tooth  pulp  and  the  main  nerve  at  the  apical  end  of  the  root.  The 
extension  of  disease  from  a  pyorrhea  pocket  may  also  cause  the  same 
result  without  its  being  discovered.  The  pulp  itself,  having  thus  become 
devitalized,  continues  to  supply  a  more  or  less  constant  infection  which 
is  forced  up  through  the  apical  end  of  the  root  by  the  gases  formed  from 
gangrenous  conditions  within  the  pulp  chamber,  and  is  doubly  danger- 
ous because  of  the  likelihood  of  direct  absorption  into  the  general  system 
or  distribution  through  the  bone  circulation. 

4.  If  the  teeth  are  irregular  there  will  in  all  probability  be  a  high 
narrow  palate  also.  These  defects  are  commonly  associated  with 
deflections  of  the  nasal  septum,  contracted  nares,  spurs,  and  attendant 
chronic  atrophic  and  hypertrophic  internasal  conditions,  which  in 
turn  may  be  held  responsible  for  diseased  nasal  secretions,  the  invari- 


542  SURGERY  OF  THE  MOUTH  AND  FACE 

able  results  of  which  are  pathological  affections  of  the  nasal  accessory 
sinuses  and  the  long  train  of  local  as  well  as  general  s\Tiiptoms  which 
may  be  expected  in  such  cases.  Such  individuals  are  also  frequently 
subject  to  mastoiditis  and  middle-ear  disease 

5.  The  abraded  edges  of  the  teeth  will  often  show  tendency  to 
nervous  disturbances  indicated  by  tooth  grinding  in  connection  with 
which  headaches,  afl'ections  of  the  eye,  neurasthenia,  and  similar 
affections  frequently  occur. 

6.  There  should  be  a  careful  examination  of  the  tongue  to  disclose 
evidences  of  chronic  ulceration,  the  character  of  its  surface,  whether 
clean  or  thickly  coated  or  deeply  fissured  or  affected  by  leukoplakia. 
Protrusion  of  the  tongue  should  also  be  insisted  upon  to  show  by  its 
extent  or  deflection  to  one  side  or  the  other,  the  presence  or  absence  of 
nervous  conditions  which  might  affect  its  proper  control.  Carefully 
taken  rontgenograms  must  be  the  chief  diagnostic  aids  in  determining 
the  presence  or  absence  of  foci  of  infection  in  this  region. 

PYORRHEA  ALVEOLARIS. 

Pyorrhea  alveolaris  {Bigg's  Disease,  Chronic  Alveolitis,  Calcic 
Pericementitis,  Phagedenic  Pericementitis)  and  other  terms  have  been 
variously  used  to  describe  a  chronic  disease  which  affects  the  gum 
borders,  the  pericementum  of  the  roots  of  the  teeth  and  their  surround- 
ing alveolar  structures,  and  which  Talbot  has  included  in  the  more 
technically  correct  term  Interstitial  gingivitis. 

Surgical  Aspect.^ — This  affection  has  long  been  known  to  be  intimately 
associated  with  many  serious  general  affections  as  an  etiologic  factor 
of  importance  and  as  an  indicative  sjinptom.  Recent  developments 
in  the  study  of  focal  infections  have  emphasized  the  frequency  of  its 
occurrence  and  the  serious  character  of  its  influence  as  a 'source  of 
infection  of  far-reaching  pathological  importance.  It  is  therefore  a 
subject  of  vital  surgical  interest. 

A  number  of  authors  agree  that,  roughly  estimated,  95  per  cent,  of  all 
persons  are  more  or  less  affected  by  this  condition.  Whether  the  actual 
percentage  be  more  or  less  than  this,  the  fact  remains  that  chronic 
inflammations  of  the  gingival  borders  and  pericementum  are  very 
generally  prevalent,  and  their  tendency  is  to  extend  until  the  surround- 
ing alveolar  structures  are  also  involved.  For  these  reasons  this  source 
of  focal  infection  cannot  properly  be  ignored  in  giving  consideration 
to  the  treatment  of  disease  whether  it  be  local  or  general  in  character. 

Etiologj.^It  is  known  that  continued  local  irritation  at  the  gingival 
borders  of  the  teeth,  as  from  calcic  deposits  about  the  necks  of  the  teeth 
or  the  disturbing  influences  of  malocclusion  and  crowded  dental  arches, 
or  imperfection  in  the  form  of  the  approximal  surfaces  of  teeth  from 
any  cause  that  may  favor  conditions  which  lead  to  the  accumulation 
of  food  particles  and  debris  in  their  interproximal  spaces,  ill-fitting 
crowns  and  bridgework,  and  similar  causes  of  local  irritation  may  be 
active,  predisposing  and  exciting  factors.    In  scurvy,  as  well  as  con- 


PYORRHEA   ALVEOLARIS  543 

ditions  due  to  the  excessive  administration  of  mercurial  preparations 
or  lead  and  other  mineral  poisons,  this  form  of  destruction  of  the 
pericemental  and  alveolar  tissues  also  occurs. 

The  presence  of  parasitic  ameboe  in  pyorrhea  alveolaris  and  other 
possible  forms  in  the  causation  of  this  disease  were  brought  to  light 
through  the  efforts  of  Dr.  Allen  J.  Smith,  Professor  of  Pathology  in  the 
School  of  Medicine,  University  of  Pennsylvania,  and  M.  T.  Barrett, 
D.D.S.,  associate  instructor  in  Normal  Histology,  Dental  Department 
of  the  University  of  Pennsylvania,  whose  preliminary  report  was 
published  in  the  August,  1914,  number  of  the  Dental  Cosmos.  In  the 
same  report  these  authors  describe  their  use  of  emetin  as  an  amebicide 
with  good  results  in  the  treatment  of  pyorrhea  pockets.  Their  belief 
in  the  efficacy  of  emetin  was  largely  based  upon  the  findings  of  Col. 
Leonard  Rogers  of  the  Indian  Medical  Service  in  Calcutta,  who  in 
1912  demonstrated  this  to  be  a  useful  as  well  as  specific  remedy  against 
the  endameba  of  dysentery. 

The  author  is  indebted  to  Dr.  Allen  J.  Smith  for  the  statement  that 
he  and  Dr.  Barrett  have  formed  the  following  conclusions:  "There  are 
two  forms  of  these  parasites  which  may  be  found  in  and  about  the 
mouth,  viz:  endameba  gingivalis  (Gros  in  1849  appears  to  have  been 
the  first  to  publish  and  discover  the  amebic  parasites  in  the  soft  material 
on  and  about  the  teeth)  and  endameba  pyogenes.^  Apparently  either 
of  these  two  amebse  may  be  met  in  pyorrhea  pus,  but  the  first  is  the 
only  one  Dr.  Barrett  and  I  have  found  therein."  "We  do  not  believe 
that  these  are  alone  responsible  for  pyorrhea  suppurations,  and  do 
believe  pyorrhea  may  occur  without  their  presence,  but  we  do  believe 
they  are  present  in  the  great  majority  of  such  lesions,  which  we  speak 
of  therefore  as  amebic  pyorrhea.  We  think  their  importance  comes 
especially  from  a  symbiosis  with  the  vegetable  microorganisms  therein 
found,  and  we  believe  we  break  one  link  of  that  symbiotic  chain  when 
we  use  emetin,  which  is  an  efficient  amebicide  but  (as  far  as  known) 
only  a  poor  bactericide.  The  chain  broken  in  this  wise,  the  suppuration 
stops.  But  the  same  result  might  be  obtained  by  cleaning  out  both  the 
amebse  and  the  bacteria  by  proper  mechanical  and  antiseptic  work, 
or  it  might  be  obtained  by  efficient  bactericides  as  the  exactly  suitable 
vaccine  for  the  individual  case.  To  attack  the  amebic  end  of  this 
symbiotic  chain  by  emetin  is  the  easy  method,  and  seems  to  be  proving 
commonly  the  most  efficient  method;  but  we  would  be  improperly 
quoted  if  we  were  held  to  regard  it  as  the  only  method." 

Pathology. — Beginning  with  a  slight  gingivitis  a  chronic  inflamma- 
tory condition  is  established  at  the  gum  border,  which  extends  to  the 
pericementum  of  the  root,  causing  slight,  though  often  imperceptible, 
elongation  of  the  affected  tooth.  (The  term  pyorrhea  dentalis  suggested 
for  the  disease  at  this  stage  is  likely  to  be  misleading  because  of  the 
practical  impossibility  of  drawing  such  a  line  of  distinction  without 
microscopic  confirmation.)     A  discharge  of  pus  becomes  established 

1  Verdum  and  Bruyant:  L'ficho  Med.  du  Nord.,  1907,  xi,  375. 


544  SURGERY  OF  THE  MOUTH  AXD  FACE 

and  absorption  of  the  alveolar  border  with  corresponding  destruction 
of  the  pericemental  and  periosteal  tissues  results  in  the  formation  of 
distinct  pockets  upon  one  or  more  aspects  of  the  affected  roots. 

^Microscopic  sections  of  these  cases  show  that  the  surrounding  bone 
is  also  more  or  less  extensively  involved.  Lacunar  and  Haversian  canal 
absorption  as  well  as  Halisterisis  have  been  demonstrated  by  Talbot 
to  be  extended  far  beyond  the  area  immediately  surrounding  the 
pocket.  As  the  disease  advances  the  necks  of  the  teeth  become  exposed, 
the  teeth  loosened  and  ultimately  lost.  Devitalization  of  the  dental 
pulp  due  to  destruction  of  the  nerves  and  vessels  at  the  apex  of  the 
root  sometimes  adds  seriously  to  the  activity  of  pus  formation. 

Sjonptoms. — The  most  noticeable  s\Tnptoms  of  this  affection  are 
discharge  of  pus  from  pockets  about  the  necks  and  roots  of  the  affected 
teeth.  These  also  become  elongated  and  loosened  and  finally  drop 
out  if  the  disease  be  unchecked. 

Diagnosis. — The  recognition  of  pyorrhea  alveolaris  when  fully 
established  is  a  simple  matter.  Pressure  upon  the  gums  about  the 
necks  of  the  teeth  discloses  the  presence  of  pus;  the  loose  teeth  and 
receding  giuns  are  at  once  noticeable.  The  incipient  stages,  however, 
are  not  so  easily  recognized.  It  sometimes  takes  careful  observation 
to  note  the  slight  local  redness  which  may  be  the  indication  of  an  early 
stage  at  which  slight  corrective  intervention  would  be  sufficient. 

Prognosis. — Inasmuch  as  there  is  no  evidence  that  the  pericementum 
when  once  destroyed  and  a  root  surface  thus  exposed  is  ever  regen- 
erated, and  since  there  can  be  no  direct  union  between  gum  tissue  or 
any  fibrous  substitute  and  such  a  root  surface,  it  follows  that  no 
matter  how  tightly  the  gmns  may  contract  as  in  many  reported  cures, 
such  areas  must  continue  to  favor  the  recurrence  of  infection.  This 
tendency  can  only  be  overcome  by  absorption  or  shrinking  down  of 
overlying  gum  tissue  of  the  pocket  in  the  course  of  contraction.  This 
result  may  follow  destructive  processes  or  be  accomplished  by  surgical 
removal  of  free  gum  tissue  to  obliterate  pockets  do^^^l  to  the  denuded 
bone  at  the  pericemental  border  of  the  lesion.  The  prediction  as  to 
the  permanency  of  beneficial  results  that  may  have  been  accomplished 
in  treatment  by  any  method  or  remedy  must  necessarily  be  governed 
by  the  completeness  with  which  this  difficulty  may  be  overcome  and 
the  efficiency  with  which  other  predisposing  factors  may  have  been 
controlled.  It  is  of  the  greatest  importance  that  the  patient  be  given 
minute  directions  to  cleanse  the  teeth  before  and  after  eating  after 
this  condition  has  been  cured  in  order  to  prevent  reinfection  which 
is  favored  by  the  condition  of  the  gums  after  recovery  from  this 
condition. 

Treatment. — Treatment,  so  far  as  the  surgeon  is  concerned,  consists 
in  recommending  the  extraction  of  hopelessly  loose  teeth  which  cannot 
be  restored  to  usefulness  and  which  must  continue  to  be  a  menace. 
The  thorough  cleansing  of  the  teeth  is  necessary,  and  the  correction 
of  any  existing  malocclusion  of  the  teeth.  Attention  should  also  be 
given  to  the  regulation  of  intestinal  conditions.    This  treatment  may 


PYORRHEA  ALVEOLARIS  545 

be  supplemented  by  the  administration  of  em,etin,  but  the  emetin 
treatment  so  often  proves  ineffective,  that  tincture  of  iodin  as  recom- 
mended by  Talbot  is  a  much  more  reliable  remedy.  This  should  be 
applied  to  the  gums  with  an  applicator  of  cotton  wound  on  wooden 
toothpicks.  Further  treatment  of  this  condition  should  be  carried  out 
by  a  competent  dentist. 

Talbot's  lodoglycerole 

I^ — Zinc.iodid 15  parts 

Distilled  water 10      " 

Iodin  crystals -      .      .      .  25      " 

Glycerin 50      " 

Sig. — ^Apply  to  gum  with  an  applicator. 

In  explanation,  it  is  important  to  note  that  by  artificial  means, 
through  local  irritation,  the  discharge  of  pus  from  the  alveoli,  the  for- 
mation of  pockets  about  the  roots,  with  ultimate  loosening  and  loss 
of  the  teeth  involved,  can  be  induced  notwithstanding  every  kind  of 
therapeutic  treatment  that  might  be  applied.  The  continual  admin- 
istration of  mercury,  and  scurvy  caused  by  the  elimination  of  all 
vegetable  foods  from  the  diet  can  also  cause  disease  of  the  gums,  the 
pericementum  and  the  alveolar  structures  with  similar  results  no 
matter  what  degree  of  careful  local  cleanliness  may  be  observed. 

The  continued  movement  of  a  tooth  in  its  socket  will  cause  bone 
absorption  with  corresponding  loosening  and  a  reduction  of  local 
resistance  which  will  render  its  surrounding  structures  extremely 
susceptible  to  all  infectious  influences.  Bearing  in  mind  these  facts, 
it  becomes  evident  that  the  ideal  treatment  for  pyorrhea  alveolaris 
must  be  one  that  includes  the  careful  elimination  of  every  form  of 
local  irritation  in  so  far  as  may  be  possible ;  the  fixation  of  loosened 
teeth;  the  careful  correction  of  adverse  intestinal  conditions  by  dietetic 
regulation. 

Ionic  Medication.- — Dr.  Percy  B.  Wright,  of  Milwaukee,  reports  good 
results  from  ionic  medication  according  to  the  method  advocated  by 
Ernest  Sturridge,'^  who  states  that  treatment  consists  in  thorough 
instrumentation,  removing  every  particle  of  foreign  substance  and 
polishing  the  necks  of  the  teeth.  Ionic  medication  indicated  consists 
in  passing  zinc  ions  into  the  gingival  trough.  A  zinc  electrode,  spear 
shaped,  of  large  enough  size  to  readily  enter  the  trough  should  be 
wound  at  the  point  with  a  little  cotton-wool,  saturated  with  3  per  cent, 
zinc  chloride  solution  and  passed  into  the  space;  the  current  from  the 
positive  pole  should  then  be  turned  on  gradually,  the  patient  holding 
the  negative  electrode.  The  teeth  should  be  kept  free  from  moisture 
from  the  mouth,  the  electrode  should  be  very  slowly  moved  around  the 
necks  of  the  teeth,  which,  if  not  sensitive,  will  tolerate  2  or  3  ma. 
current.  The  trough  is  in  this  manner  sterilized  with  zinc  ions  which 
migrate  readily  even  with  very  much  less  current  strength.  The  time 
required  to  go  round  each  tooth  should  occupy  on  an  average  about  a 
minute,  some  places  requiring  a  longer  time,  others  less  affected,  a 

1  Dental  Electrotherapeutics,  Lea  &  Febiger,  1918. 
VOL.  I — 35 


546  SURGERY  OF  THE  MOUTH  AND  FACE 

shorter.  Discretion  must  be  used  in  the  matter  of  time  required  to 
sterilize  soft  tissues.  Ions  are  conductors  of  current  and  move  instan- 
taneously, the  time  and  current  strength  work  in  direct  ratio  to  each 
other  to  produce  depth  of  penetration.  In  mucous  tissue  (2  ma. 
current  with  a  small  area  electrode)  the  current  density  is  very  great, 
and  the  dose  of  ions  provided  in  one  minute  over  a  small  area  of  a 
gingival  border  must  be  considerable. 

One  treatfnent  will  often  be  sufEcient  if  all  foreign  matter  has  been 
completely  removed,  and  the  teeth  polished,  but  the  patient  should 
be  seen  in  three  or  four  days,  and  if  this  condition  has  not  been  fulfilled, 
redness  and  congestion  will  be  present  wherever  any  irritant  is  lurking. 
This  should  be  removed,  and  the  affected  part  treated  as  before. 

According  to  Smith  and  Barrett  the  directions  for  the  use  of  emetin 
are  as  follows : 

"The  solution  is  introduced  in  the  pyorrhea  pockets  with  an  ordi- 
nary hypodermic  syringe  with  a  straight  or  curved  needle  as  needed, 
so  as  to  gain  access  to  all  parts  of  the  pockets.  The  point  of  the  needle 
should  pass  along  the  root  of  the  tooth  to  the  bottom  of  the  pocket, 
merely  engaging  with  the  wall,  and  be  carried  about  to  all  of  its  parts. 
In  one  sense,  of  course,  it  would  be  well  to  actually  penetrate  the  wall 
of  the  pocket,  and  thus  in  the  discharge  of  the  solution  insure  diffu- 
sion of  the  emetin  in  the  surrounding  tissues.  However,  this  is  not 
essential,  and  the  mechanical  harm  done  to  the  wall  by  the  instru- 
mental puncture,  and  that  occasioned  by  carrying  infective  material 
through  the  wall  by  the  penetrating  point,  are  sufficient  reasons  for 
trying  to  avoid  such  strenuous  and  unnecessary  efforts.  Unquestion- 
ably bothersome  local  inflammation  can  be  occasioned  by  failure  to 
avoid  this  source  of  irritation.  Each  pocket  in  turn  is  thus  filled 
with  the  emetin  hydrochlorld  solution.  Treatments  which  thus 
include  all  recognizable  pockets  and  special  parts  under  suspicion 
should  be  repeated  daily  for  at  least  five  days,  and  thereafter  every 
other  day  until  about  ten  treatments  as  a  total  have  been  made,  as 
a  general  rule.  In  some  of  the  less  marked  and  less  chronic  cases,  a 
total  of  five  or  six  applications  or  even  less  may  be  sufficient,  while 
in  the  more  stubborn  instances  treatment  must  be  continued  even 
longer  than  above  indicated."^ 

Drs.  Bass  and  Johns  favor  the  hypodermic  administration  of  ipecac 
and  prescribe  ^  grain  emetin  hydrochlorid  hypodermically  each  day 
for  from  three  to  six  days,  depending  on  the  case  and  stage  of  the 
disease,  but  clinical  results  do  not  seem  to  warrant  this  practice. 

Trench  Mouth. — An  infection  with  which  pyorrhea  alveolaris  is 
easily  confused  and  sometimes  associated  and  which  has  been  commonly 
known  as  trench  mouth  during  the  war  is  Vincent's  disease  or  a  fuso- 
spirochetal infection  of  the  mouth.  It  may  affect  the  tonsils  from  which 
a  yellow  sloughing  ulcer  often  spreads  to  the  soft  palate  and  other 
parts  of  the  mouth.  A  second  form  affects  more  particularly  the  gums 

'  Dental  Cosmos,  December,  1914,  vol.  Ivi,  No.  12. 


CYSTS  OF  THE  MOUTH  AND  JAWS  547 

and  closely  resembles  pyorrhea  alveolaris.  Another  type  of  the  disease 
causes  a  general  inflammation  of  the  mouth  and  is  not  infrequently 
fatal  in  its  results. 

The  microorganisms  present  are  the  fusiform  bacilli,  spirochete  and 
a  spirillum. 

The  diagnosis  is  by  microscopic  examination  and  differentiation 
must  be  made  from  diphtheria,  syphilis,  pyorrhea  alveolaris  and  other 
forms  of  stomatitis. 

Treatment. — The  author's  method  of  treatment  in  these  cases,  which 
are  still  quite  prevalent  among  the  returned  soldiers,  is  to  isolate  the 
individual  in  so  far  as  possible,  particularly  with  reference  to  eating 
utensils,  spoons,  knives,  forks,  cups,  etc. 

The  mouth  is  rinsed  once  each  hour  with  dioxygen  and  listerine  or 
some  o'ther  suitable  antiseptic  mouth  wash  used  alternatively.  The 
gums  are  thoroughly  swabbed  twice  daily  with  cotton  applicators 
dipped  in  iodin.  Salvarsan  sprinkled  upon  the  surface  of  the  ulcers  or 
salvarsan  in  glycerin  swabbed  over  the  afi^ected  surfaces  appears  to 
be  particularly  useful.  Intravenous  administration  of  salvarsan  has 
been  disappointing  and  is  at  least  uimecessary  except  for  syphilitics. 
As  depleted  conditions  of  the  system  whether  from  cigarette  smoking 
or  other  causes  render  the  system  more  susceptible  to  the  Vincent's 
microorganisms,  this  feature  requires  attention  by  building  up  the 
bodily  resistance.  Usually  the  cases  yield  to  treatment  quite  readily 
and  when  repeated  cultures  from  the  mouth  show  absence  of  the  micro- 
organisms, the  patient  may  safely  be  dismissed. 

CYSTS    OF   THE   MOUTH   AND   JAWS. 

A  cyst  consists  of  a  connective-tissue  membrane  or  supporting  wall 
lined  by  epithelimn  or  endotheliiun,  the  contents  of  which  may  be 
fluid  or  semifluid,  uniform  in  composition,  or  made  up  of  a  mixture 
of  similar  or  dissimilar  substances. 

Cysts  may  be  simple  or  muUi'ple. 

Classification. — (1)  Retention  cysts  due  to  the  occlusion  of  excretory 
ducts  of  glands.  (2)  Exudation  cysts,  caused  by  accumulations  in 
cavities  not  supplied  by  excretory  ducts.  (3)  Cystoma,  a  cyst  that  is 
the  result  of  a  new  formation.  (4)  Extravasation  cysts,  those  formed 
around  distended  or  ruptured  vessels.  (5)  Dermoid  cysts,  congenital 
cystic  results  of  cutaneous  inclusion.  (6)  Parasitic  cysts,  caused  by 
animal  organisms,  as  trichinae  and  other  parasites.  (7)  Cysts  result- 
ing from  necrotic  and  degenerative  changes  in  solid  tissues,  such  as  those 
formed  in  neoplasms  from  hemorrhage  liquefaction,  necrosis,  and  other 
forms  of  softening,  as  well  as  other  degeneration  processes. 

Proliferous  when  the  cyst  walls  continue  to  spring  from  each  other 
or  proliferate. 

Multilocular  when  a  number  of  cysts  together  remain  distinct,  and 
cavernous,  when  these  communicate. 

Retention  Cysts  of  the  Mucous  Glands. — Retention  cysts  of  the 
mucous  glands  are  caused  by  occlusion  of  the  ducts  of  these  glands. 


548  SURGERY  OF  THE  MOUTH  AND  FACE 

Symptoms. — ^These  small  pink  or  bluish  cysts  may  appear  on  any 
part  of  the  surface  of  the  mucous  membrane  of  the  mouth.  Occasion- 
ally they  increase  in  size  until  large  enough  to  interfere  with  the 
movements  of  the  tongue  or  the  occlusion  of  the  teeth. 

Treatment.^ — Extirpation  with  care  not  to  rupture  the  cyst,  wall, 
thereby  removing  the  cyst  and  its  contents  intact,  is  the  best  method 
of  treatment.  The  mucous  membrane  edges  of  the  wound  sulfaces 
are  then  sutured  with  gut.  Treatment  by  cauterization  and  ^rette- 
ment  are  usually  less  effective  and  much  more  troublesome,  because 
any  position  of  the  lining  which  has  not  been  destroyed  will  surely 
cause  a  recurrence. 

Deep-seated  Cysts  of  the  Mucous  Membrane. — Deep-seated  cysts 
of  the  mucous  membrane  sometimes  have  their  origin  under  the 
foramen  cecum  and  the  third  tonsil. 

Symptoms. — In  these  cases  contact  with  the  epiglottis  sometimes 
causes  irritation  and  the  resulting  cough  may  be  mistaken  for  an  indi- 
cation of  some  other  affection.  It  is  also  frequently  difficult  to  dis- 
tinguish enlargement  due  to  cysts  of  this  character  from  hypertrophy 
of  the  lingual  tonsil. 

Diagnosis. — Their  diagnosis  depends  chiefly  upon  examination  with 
the  aid  of  a  lar\iigeal  mirror. 

Treatment. — Complete  surgical  removal  or  destruction  by  cauteri- 
zation is  required. 

Cysts  of  the  Glands  of  Blandin-Nuhn. — Cysts  of  the  glands  of 
Blandin-Nuhn  appear  in  rare  cases  on  the  tip  of  the  tongue.  They 
are  covered  with  pale  red  mucosa,  are  transparent,  and  occasionally 
become  quite  large. 

Treatment." — Extirpations  as  for  other  mucous  cysts. 

Ranula. — Although  this  term  has  been  somewhat  loosely  applied 
to  retention  cysts  in  the  floor  of  the  mouth,  it  should  be  used  to  describe 
more  particularly  cysts  of  the  sublingual  and  submaxillary  glands. 

Etiology. — Occlusion  of  the  ducts  of  these  glands  causes  salivary 
retention.  Sometimes  this  occurs  from  a  congenital  defect  of  the 
ducts,  but  usually  as  a  result  of  some  inflammatory  process. 

Symptoms. — Swelling  under  the  tongue  causes  it  to  be  displaced 
upward.  Usually  this  appearance  is  confined  to  one  side,  but  through 
great  enlargement  the  cyst  may  extend  completely  across  the  mouth. 

A  ranula  is  commonly  filled  with  a  light-colored  viscid  fluid.  Some- 
times this  has  a  bro\Miish  color  and  occasionally  it  is  tinged  with  red 
or  green.  Such  cysts  may  grow  slowly  or  they  may  occasionally 
develop  rapidly  in  the  course  of  a  few  hours. 

Diagnosis. — The  situation  differentiates  ranula  from  mucous  cysts; 
its  consistency  and  mobility  from  other  more  solid  growths.  Com- 
parative rapidity  of  increase  in  size  distinguishes  it  from  dermoid 
cysts  which  sometimes  occur  beneath  a  submaxillary  gland  and  cause 
upward  displacement  of  the  floor  of  the  mouth  and  tongue. 

Treatment.— Opening  a  ranula  causes  it  to  collapse  immediately  but 
it  fills  up  again  almost  as  promptly.     Removal  of  the  gland  or  dis- 


CYSTS  OF  THE  MOUTH  AND  JAWS 


549 


secting  out  the  cyst  wall  may  be  effective,  but  is  usually  unnecessarily 
troublesome  as  is  also  the  attempt  to  destroy  the  cyst  by  cauteriza- 
tion or  curettement  or  packing  with  powerful  acids.  The  reestablish- 
^^^rtnent  of  ducts  to  allow  continuous  escape  of  saliva  is  a  simple  and 
very  effective  method  of  treatment.  This  is  easily  accomplished,  as 
shown  in  Fig.  298,  by  passing  a  wire  loop  completely  through  the 
cyst,  securing  the  ends  of  the  wire  by  a  compressed  lead  shot  and  bend- 
ing it  in  such  a  form  as  to  enable  it  to  rest  under  the  tongue  without 


F  Fig.  298. — Illustration  of  a  raniila  with  wire  loop  in  place  as  treated  in  the  case  of  a 
young  girl  ten  years  of  age.  Although  operated  upon  several  times  before,  the  ranula 
never  appeared  again  after  insertion  of  the  wire  loop. 


irritation  or  annoyance.  The  natural  activity  of  the  tongue  causes 
sufficient  movement  of  the  wire  back  and  forth  to  prevent  complete 
closure  of  the  opening.  It  may  be  allowed  to  remain  in  place  for  sev- 
eral weeks  or  months,  if  necessary,  to  ensure  the  permanence  of  the 
openings  after  the  wire  is  removed.  The  importance  of  emphasizing 
the  value  of  this  simple  procedure  has  recently  been  brought  home 
to  the  author  through  some  cases  in  which  great  anxiety  had  been  occa- 
sioned by  the  frequent  recurrence  of  the  cyst  after  treatment,  and 
much  unnecessary  suffering  endured  by  the  patient  through  ineffectual 


550 


SURGERY  OF  THE  MOUTH  AND  FACE 


attempts  to  extirpate  and  also  to  destroy  the  cyst  wall  with  powerful 
acids.  It  is  only  a  momentary  matter  to  pass  a  needle  through  the 
ranula  with  no  appreciable  pain.  The  wire  when  properly  placed 
gives  no  annoyance,  and  the  gland  resumes  its  natural  function 
without  delay. 

Hydrops  of  the  Sublingual  Bursa. — Skillern  quotes  Fleischmann 
and  Lennon  as  being  convinced  that  ranula  arises  through  disease  of 
the  sublingual  mucous  bursa  alone,  the  salivary  duct  only  at  times 
being  involved  in  the  same  fashion.  He  quotes  Tillaux^  as  being  of 
the  same  opinion  and  gives  Fleischmann's  description  of  this  bursa  as 
illustrated  in  Figs.  299  and  300.     He  describes  a  case  apparently  like 


Fig.  299. — Sublingual  mucous  bursa, 
called  Fleischmann's,  seen  upon  an  antero- 
posterior section  of  the  floor  of  the  mouth. 

A,  ca\'ity  of  the  sublingual  mucous  bursa; 

B,  its  anterior  or  mucoiis  wall;  C,  its  pos- 
terior or  muscular  wall;  D,  the  dotted  line 
indicating  the  depth  of  the  bursa;  E,  the 
duct  of  Wharton;  F,  the  sublingual  gland; 
G,  the  genioglossus  muscle. 


Fig.  300. — Sublingual  mucous  bursa 
seen  from  the  front  after  one  has  previ- 
ously raised  the  anterior  or  mucous  wall. 
A, A,  interspace  between  the  two  genio- 
glossus muscles;  B,B,  borders  of  the 
mucous  bursa. 


ranula  which  continued  after  removal  of  the  sublingual  and  maxillary 
glands  and  which  he  found  was  situated  in  the  sublingual  mucous 
bursa. 

"A  T-shaped  submandibular  incision  was  made  over  the  swelling; 
on  reflecting  the  skin  and  superficial  fascia  there  was  exposed  a  lax 
cyst  with  a  thin,  bluish-white  wall.  On  opening  the  cyst  there  escaped 
a  clear,  glairy  fluid.  The  orifice  of  communication  through  the  mylo- 
hyoid muscle,  corresponding  to  the  constriction  of  an  hour-glass,  was 
tightly  closed  by  a  catgut  suture,  thus  dividing  the  cyst  wall  into  two 
cavities:  an  upper  oral,  and  a  lower  cervical.    The  lower  cervical  was 

'  Anatomie  topographique,  p.  326;  Lectures  on  Surgical  Pathology,  1854,  p.  335; 
Schmidt's  Jahrb.,  1841,  xxxii,  88. 


CYSTS  OF  THE  MOUTH  AND  JAWS 


551 


stuffed  with  gauze,  aiming  at  adherence  of  its  walls  by  obliterating 
granulation  tissue.  The  upper  oral  cavity  was  marsupialized  into  the 
mouth  cavity  and  likewise  stuffed  with  gauze,  with  the  same  end  in 
view." 

Periosteal  Cysts  of  the  Jaws. — These  cystic  cavities  occur  in  con- 
nection with  the  roots  of  teeth,  or  in  sites  that  have  formerly  been 
affected  by  dento-alveolar  abscesses  even  though  the  primary  cause 
may  have  been  removed.  Their  distinguishing  feature  is  the  lining 
membrane.  Turner  believes  this  to  be  an  epithelial  lining  probably 
developing  from  a  peridental  epithelial  remnant. 

Symptoms. — The  fluid  contents  of  these  cysts  may  represent  any  of 
the  characteristic  results  of  tissue  liquefaction.  They  are  usually 
painless  and  develop  slowly.  The  external  thin  bony  wall  is  some- 
times forced  outward,  and  thus  its  bulging  facilitates  diagnosis,  but 
rontgenograms  give  the  most  prompt  and  satisfactory  diagnostic 
indications  of  their  presence,  size  and  character. 


Fig.  301. — Radiograph  of  a  cyst  of  the  lower  jaw. 


Treatment. — Treatment  consists  of  complete  removal  of  the  cause, 
destruction  of  the  cyst  wall,  and  also  of  surrounding  bone  that  may 
be  affected.  Packing  the  resulting  bone  cavity  with  gauze  is  occasion- 
ally required  but  this  should  be  avoided  whenever  it  may  be  possible 
to  give  sufficient  protection  against  infection  by  constant  cleansing 
of  the  mouth  and  wound  surfaces  with  suitable  antiseptic  solutions. 
Moorhead  recommends  exposing  the  cyst  by  raising  a  flap  of  perios- 
teum with  overlying  tissue  and  suturing  this  into  place  again  without 
packing  the  area  of  bone  excavation. 

Multilocular  Cysts. — Multilocular  cysts  may  originate  through  the 
agency  of  diseased  roots  of  teeth  or  follicular  odontomas.    These  col- 


552 


SURGERY  OF  THE  MOUTH  AND  FACE 


lections  of  cysts  sometimes  grow  to  an  enormous  size  as  shown 
in  Fig.  302.  They  result  from  embryonic  inclusion  of  epithelial 
cells. 

Diagnosis  and  Prognosis. — In  diagnosis  such  cysts  are  easily  recog- 
nized. The  prognosis  in  these  cases  is  more  or  less  doubtful.  They 
sometimes  show  a  tendency  to  continue  to  proliferate  and  grow,  espe- 
cially if  not  completely  removed. 

Treatment. — All  of  the  cysts  must  be  removed  and  a  sufficiently 
large  area  of  surrounding  bone,  even  though  resection  of  the  jaw 
may  be  necessary,  to  give  protection  against  recurrence. 


I  Fig.  302. — Multilocular  cyst.     (Westmoreland.) 


Proliferous  Cysts. — Proliferous  cysts  border  closely  on  true  tumors 
in  their  nature.  They  may  appear  in  any  glandular  organ  but  are 
most  frequently  found  in  the  mammary  gland  and  ovary.  These 
cysts  contain  serous  or  gelatinous  fluid,  and  occasionally  the  contents 
are  hemorrhagic  in  character.  They  are  lined  with  typical  or  columnar 
epithelium  and  stroma  or  reticulum  of  connective  tissue.  They  may 
be  unilocular  or  multilocular  and  by  communication  of  the  numerous 
loculi  may  become  cavernous. 

Treatment. — Because  of  the  uncertainty  of  their  exact  character 
they  should  be  treated  as  malignant  growths. 

Dermoid  Cysts. — Simple  dermoid  cysts  may  form  in  any  part  of  the 
body  where  epithelial-lined  surfaces  are  united  during  fetal  develop- 
ment. Whenever  a  sinus  that  may  persist  through  incomplete 
development  becomes  closed  at  both  ends  the  cavity  may  be  dilated 
into  a  cyst  by  the  accumulation  of  secretions. 

Teratomas  or  Compound  Dermoid  Cysts. — Teratomas  or  compound 
dermoid  cysts  are  lined  with  epithelium  and  may  contain  a  variety 
of  structures  such  as  hair,  teeth,  etc.  Fig.  303  shows  a  dermoid  of 
the  neck  which  by  displacement  of  the  tongue  and  the  floor  of  the 


CYSTS  OF   THE  MOUTH  AND  JAWS 


553 


mouth  made  diagnosis  quite  confusing.  Its  exact  nature  was  discovered 
upon  removal. 

Parasitic  Cysts. — Parasitic  cysts,  such  as  the  hydatid  cysts  caused 
by  Tsenia  echinococcus  or  dog  tapeworm,  have  been  found  m  the 
mouth  in  rare  instances. 

Bertele  reports  finding  them  in  the  temporal  and  masseter  muscles.^ 


Fig.  303. — Portion  of  a  wall  of  an  ovarian  dermoid  cyst:  a,  wall  of  the  cyst;  b,  projecting 
portion  made  up  of  fatty  and  cutaneoas  tissue;  c,  hairs;  d,  teeth.     (Ziegler.) 

Odontomas. — ^An  odontoma  is  defined  as  a  tumor  composed  of  one 
or  more  dental  tissues  arismg  either  from  tooth  changes  or  teeth  in 
the  process  of  development.  In  classification  Broca  divides  odontomas 
accordmg  to  the  stage  of  development  of  the  dental  follicles  at  which 
they  occiu-,  into  embryoplastic  when  developing  in  the  dental  sac, 
odontoplastic  when  soft  tumors  may  occur,  and  a  third  when  the  tumors 
are  composed  of  calcified  tooth  structures.  These  again  are  subdi- 
vided into  crown  and  root  formation  as  indicated  by  their  being  com- 
posed of  enamel,  dentine,  or  cementum,  or  a  composite  combination 
of  these. 

]Mallory-  describes  three  t^-pes  of  tumors  which  are  recognized  as 
arising  from  the  enamel  organ. 

"  (1)  The  follicular  cyst  which  is  lined  mth  pavement  epithelium, 
the  inner  wall  of  which  often  bears  a  single  and  sometimes  several 
cells.  (2)  Adamantinoma  which  grows  as  branching  masses  of  epithe- 
lial cells.  Those  cells  adjoining  the  stroma  correspond  to  adamanto- 
blasts  while  others  form  the  enamel  pulp.  They  grow  expansively 
only  and  produce  no  metastases.  (3)  Occasionally  the  adamantinoma 
produces  tA-pical  enamel.    More  often  it  converts  the  adjoining  fibro- 

1  Bulletin  of  von  Bergmann,  p.  521. 

2  Principles  of  Pathology  and  Histologj\ 


554 


SURGERY  OF  THE  MOUTH  AND  FACE 


blasts  into  odontoblasts.  When  this  happens  separate  teeth  or  fused 
masses  of  them  of  various  sizes  may  be  produced.  Cementum  may 
also  be  formed." 

Some  confusion  in  classification  of  odontomata  occurs  by  reason  of 
the  fact  that  teeth  are  developed  from  epiblastic  and  mesoblastic 
structures.  For  this  reason  odontoma  cannot  be  classified  with  the 
epithelial  groups  in  the  strict  sense.  It  is  of  the  adult  type  and  there- 
fore may  not  be  classified  with  the  teratoma  or  mixed  epithelial  and 
connective-tissue  tumors  because  these  are  both  adult  and  embryonic, 
whereas  the  odontoma  is  adult  and  therefore  benign. 

Bland-Sutton^  classifies  odontomes  according  to  the  part  of  the 
tooth  germ  from  which  they  appear  to  originate. 

Epithelial  Odontomas. — Epithelial  odontomas  develop  in  the  remains 
of  the  epithelium  in  the  original  enamel  organ. 

Symptoms. — They  appear  in  the  form  of  a  series  of  cysts  separated 
by  thin  septa  and  contain  mucoid  fluid.  The  color  during  growth  is 
slightly  red  and  not  unlike  sarcoma. 


Fig.  304. — Cyst  of  the  lower  jaw,  ha-\'ing  its  origin  about  an  undeveloped  tooth.  • 

(Garretson.) 

Follicular  Odontoma  or  Dentigerous  Cyst. — These  cysts  form  in 
connection  with  developing  permanent  teeth. 

Symptoms. — The  bony  walls  become  thin  from  the  formation  of 
fluid  \\'ithin  the  cyst  and  sometimes  bulge  out  in  such  manner  as  to 
cause  great  deformity.  The  inner  wall  of  the  cyst  represents  the 
remains  of  the  dental  follicle  within  which  there  is  a  tooth  or  part  of 
a  tooth.  The  cyst  is  filled  with  fluid  usually  serous  or  mucoid,  but 
occasionally  of  dark  bro^^^l  color.  Ordinarily  they  do  not  become 
purulent,  but  occasionally  through  infection  this  does  occur,  and  may 
result  in  severe  inflammatory  conditions  (Fig.  304). 


1  Tumors,  Innocent  and  Malignant. 


CYSTS  OF  THE  MOUTH  AND  JAWS     ,  555 

Compound  Follicular  Odontomas. — The  follicle  wall  becomes  thick- 
ened into  a  fibrous  capsule.  In  this  there  may  be  portions  of  dentin, 
enamel,  or  cementum,  combined  with  more  or  less  imperfectly  formed 
teeth. 

Diagnosis. — Myxomatous  and  fibromatous  forms  of  soft  odontoma, 
both  of  which  are  formed  during  the  embryoplastic  or  odontoplastic 
periods,  are  frequently  difficult  to  differentiate  from  other  tumors  of 
the  jaw,  notably  cysts,  fibroids,  and  sarcoma. 

The  diagnostic  guides  are  slow  growth,  freedom  from  pain,  irregular 
surface  on  section,  masses  of  cement  or  dentin  which  may  occasion- 
ally be  found  to  be  encapsuled,  and  microscopic  examination.  Of  the 
hard  forms,  dentigerous  cysts  are  usually  discovered  by  the  yielding 
of  the  thin  bulging  wall  on  pressure,  with  perhaps  a  crepitant  sound ; 
puncture  to  reveal  the  character  of  the  fluid  contents,  and  on  opening 
a  tooth  is  revealed  in  the  cystic  enclosure. 

Fibrous  Odontomas. — Fibrous  odontomas  are  developed  from  the 
connective-tissue  elements  of  the  developing  tooth  by  excessive  growth 
of  the  fibrous  capsule  of  the  tooth  germ  which  is  derived  from,  and 
closely  adherent  to,  the  connective  tissue  of  the  papilla. 


Fig.  305. — Fibrous  odontome.    (Garretson,  Fig.  306. — Radiciilar  odontome. 

after  Pierce.)  (Tomes.) 

i' 

Syviptoms. — The  tumor  has  a  firm  outer  wall  with  less  firmly  con- 
nected inner  structure,  which  at  the  root  of  the  tooth  with  the  dental 
papilla  is  indistinguishable  from  it.  In  this  way  the  developing  tooth 
becomes  enclosed  within  the  capsule.  These  tumors  are  quite  fre- 
quently seen  in  animals,  especially  ruminants,  etc.  (Fig.  305). 

Cementoma. — ^This  is  a  tumor  in  which  by  calcification  of  the  capsule 
the  tooth  becomes  embedded  in  a  mass  of  cementum. 

Symptoms. — Cementomas  sometimes  attain  great  size.  Their  struc- 
ture resembles  cementum,  and  is  arranged  in  layers  somewhat  similar 
to  fibrous  odontomas.  They  are  rare  in  human  teeth  and  usually  occur 
in  the  mammalia. 

Radicular  Odontomas. — These  tumors  form  after  the  development 
of  the  crown  and  during  the  process  of  root  formation.  They  consist 
of  cementum  and  dentin  in  varying  quantities,  are  rare  in  man,  but 
frequent  in  animals  (Fig.  306). 

Composite  Odontomas. — ^These  are  abnormal  growths  of  all  the  ele- 
ments of  tooth  structure,  resulting  in  ill-formed  masses  of  cementum, 
dentin  and  enamel.  Thus  far  they  have  been  only  found  in  man 
(Fig.  307). 


556  SURGERY  OF  THE  MOUTH  AND  FACE 

According  to  Gilmer:^  "The  composite  odontoma  differs  from  the 
ordinary  dentigerous  cyst  containing  diminutive  teeth  or  dentary 
bodies,  in  that  the  dentigerous  cyst  contains  no  cement  substance 
other  than  that  which  covers  the  root  of  the  individual  tooth,  when 
perfectly  formed  teeth  are  found,  with  each  little  tooth  or  denticle 
separate  and  distinct  from  the  other;  besides  there  is  a  well-defined 
cyst  wall  and  cyst  fluid.  In  the  composite  odontomes  there  is  no 
cyst  wall  or  cyst  fluid,  so  far  as  I  have  been  able  to  discover." 


Composite  odontoma.     (Gilmer.) 


It  is  interesting  to  note  Dr.  Black's  report^  of  the  histological 
appearance  of  sections  of  a  composite  odontoma:  "I  found  all  the 
tissues  of  a  normally  developed  tooth,  but  in  a  state  of  confusion. 
There  is  an  entire  absence  of  any  proper  pulp  cavity.  The  disposition 
or  arrangement  of  the  tissues  is  peculiar  and  striking.  It  is  as  though 
there  were  a  thousand  teeth,  exceedingly  minute,  growing  as  close 
together  as  they  could  be  crowded,  and  the  interstices  between  them 
filled  up  with  enamel  and  cement.  In  the  field  of  the  microscope, 
with  the  sections  I  have,  we  shall  often  be  able  to  see  a  number  of 
these  diminutive  teeth  at  a  single  view.  Each  has  its  own  little  pulp 
chamber  in  due  form,  its  own  separate  dentin  and  its  own  enamel 
cap,  and  plastered  in  and  about  and  added  on  to  these  there  is  a  con- 
siderable amount  of  both  enamel  and  cement  of  very  irregular  forma- 
tion. Many  of  the  pulp  chambers  are  partially  filled  with  calcospher- 
ites.    These  also  appear  in  many  parts  of  the  specimen  in  profusion." 

Odontomas  may  be  recognized  by  a  sharp,  light,  steel  probe  passed 
through  the  overlying  structures  until  it  comes  .in  contact  with  the 
dense,  more  or  less  irregular  surface  of  the  tumor  which  is  recognized 
by  the  sense  of  touch.  Radiograms  give  the  best  evidence  of  the 
existence  and  character  of  all  these  tumors. 

1  Report  of  Six  Capes  of  Composite  Odontomas,  Jour.  Am.  Med.  Assn.,  1911,  Ivi, 
165-168. 

2  Illinois  State  Dental  Society,  1879. 


PLATE    VIII 


Epulis.     (Grunwald.) 


Papilloma  of  the  Gum. 


CYSTS  OF  THE  MOUTH  ANDJAWS  557 

Treatment. — The  treatment  in  all  varieties  of  odontomas  consists 
in  their  complete  removal  and  destruction  of  the  cyst  wall  if  neces- 
sary. The  surgeon  should  always  keep  in  mind  the  possibility  of  odon- 
toma in  dealing  with  the  maxillary  tumors.  This  is  particularly  true 
in  cases  of  children  and  young  persons.  In  the  author's  experience 
upon  one  occasion  it  took  several  hours  of  careful  study  and  explana- 
tion to  convince  consulting  surgeons  that  resection  of  the  jaw  was 
unnecessary  in  the  case  of  a  boy  nine  years  old  some  of  whose  develop- 
ing teeth  in  the  lower  jaw  had  become  encysted,  when  all  that  the 
case  required  for  complete  recovery  was  the  removal  of  the  upper 
wall  of  the  cyst  and  drainage  of  the  fluid  after  which  the  teeth  erupted 
in  normal  situation  and  the  swelling  disappeared.  Resection  of  the 
mandible  always  creates  more  or  less  deformity  under  every  circum- 
stance, but  it  is  particularly  deplorable  when  required  in  growing 
children  whose  jaws  are  not  yet  fully  developed  for  then  the  unavoid- 
able deformity  is  very  great.  There  have  been  notable  examples  of  the 
resection  of  such  jaws  in  uncomplicated  odontomas. 

Epulis. — Epulis  is  a  commonly  used,  but  much  confused  term 
employed  to  distinguish  growths  which  usually  originate  in  the  perios- 
teum between  or  around  the  necks  of  the  teeth  from  tooth  sockets. 
(See  Plate  VIII,  Figs.  1-2.)  Such  a  growth  might  be  papilloma, 
fibroma,  carcinoma,  sarcoma  or  any  of  the  tumors  which  might  spring 
from  the  fibrous  tissue  of  the  gum  and  periosteum,  but  it  is  generally 
understood  to  describe  giant-cell  sarcoma.  The  difficulty  is,  however, 
that  giant-cell  sarcoma  is  always  a  misleading  description  because  as 
Mallory^  states:  "At  least  two  types  of  giant  cells  occur  in  tumors. 
One  type  results  from  multiple  mitoses  and  signifies  rapid  growth. 
It  is  a  true  tumor  cell  with  characteristics  like  the  other  cells  in  the 
tumor  in  which  it  is  present.  This  kind  of  giant  cell  occurs  in  a  vari- 
ety of  rapidly  growing  tumors,  such,  for  example,  as  fibrosarcoma, 
glioma,  lymphoblastoma,  carcinoma." 

"  Giant  cells  of  the  second  type  are  found  most  commonly  in  new- 
growths  involving  bone.  They  occur  both  in  rapidly-growing  and  in 
slow-growing  tumors.  There  are  no  multiple  mitoses  to  explain  their 
origin. 

"  Giant  cells  of  this  type  produce  no  fibrils.  They  are  foreign  body 
giant  cells,  similar  to  the  osteoclasts  of  normal  bone  and  are  due  to  the 
fusion  of  endothelial  leukocytes  attracted  into  the  tumor  by  the  pres- 
ence chiefly  of  lime  salts  which  they  dissolve  and  remove.  They 
signify  usually  disintegration  of  bone,  rarely  the  presence  of  fat  and 
fat  crystals.  They  occur  most  commonly  in  fibroma  and  fibrosarcoma 
involving  bone,  in  the  stroma  of  cancer  metastases  in  bone,  and  in 
osteosarcoma." 

The  importance  of  this  distinction  cannot  be  overestimated.  The 
presence  of  giant  cells  alone  cannot  be  depended  upon  in  determining 
the   character  of  the  treatment.     (See  Plate  VIII,  Fig.  2.)     These 

1  Principles  of  Pathology  and  Histolosy. 


558  SURGERY  OF  THE  MOUTH  AND  FACE 

growths  usually  appear  upon  the  gum  and  give  httle  disturbance  out- 
side of  the  mechanical  interference  and  spread  gradually  until  the 
surrounding  structures  are  involved. 

Diagnosis.^ — In  diagnosis  the  usual  distinction  must  be  made  in 
differentiating  from  malignant  growths.  Treatment  consists  of  com- 
plete removal  down  to  and  including  the  periosteum  with  the  adjoin- 
ing teeth  as  well  as  those  immediately  involved,  and  the  removal  of 
sufficient  bone  to  include  completely  the  sockets  of  the  affected  teeth. 
As  a  matter  of  precaution  it  is  well  to  burn  the  bone  surface  with  a 
hot  iron  or  cautery.  Many  of  these  growths  removed  in  this  way  by 
the  author  have  never  shown  a  tendency  to  recur. 

MALPOSED  UNERUPTED  TEETH. 

Through  malposition  or  impaction  due  to  insufficient  size  of  the 
dental  arches,  or  for  other  reasons,  it  is  not  uncommon  to  find  unerupted 
teeth  in  the  jaws  of  adults.  These  may  belong  to  the  normal  number 
of  teeth  or  may  be  supernumeraries.  Their  surgical  significance  is 
important.  Although  such  teeth  may,  and  sometimes  do,  remain  in 
a  jaw  through  life  without  causing  noticeable  disturbance,  they  much 
more  frequently  become  serious,  though  often  unsuspected,  causal 
factors  in  a  considerable  number  of  pathologic  affections. 

Pathologic  Significance. — The  tendency  of  impacted  teeth  to  become 
encysted  and  through  degenerative  changes  to  become  predisposing 
factors  in  the  establishment  of  carcinoma  or  sarcoma  in  their  surround- 
ing tissues  is  well  known  Frequent  evidence  of  this  has  been  given 
by  their  discovery  during  operations  for  the  removal  of  such  growths. 

Such  teeth  sometimes  lie  across  the  paths  of  large  vessels  and  nerves 
and  thus  become  disturbing  influences  leading  to  a  considerable  vari- 
ety of  nervous  disorders.  In  headaches,  neuralgias,  spasmodic  affec- 
tions of  nervous  origin,  and  similar  conditions  their  presence  in  the 
jaws  may  bear  great  etiologic  significance. 

Alterations  in  the  surrounding  bone  structure,  especially  when  a 
tooth  is  erupted  sufficiently  to  communicate  with  the  surface  of  the 
mouth,  favor  the  accumulation  of  bacteria-laden  secretions.  In  this 
way  foci  of  infection  of  far-reaching  pathologic  character  may  be 
established.  The  more  or  less  constant  although  usually  unconscious 
nervous  tension  that  is  caused  by  the  presence  of  teeth  imprisoned 
in  the  jaws  has  frequently  given  rise  to  the  jaw  clinching  and  tooth 
grinding  habit  which  has  been  shown  to  have  an  important  bearing 
in  some  cases  of  neurasthenia.  In  all  disorders,  whether  local  or  gen- 
eral in  character,  in  which  peripheral  irritation  in  the  maxillary  region 
may  be  of  diagnostic  interest,  a  careful  search  should  be  made  for 
unerupted  teeth.  Many  cases  have  been  reported  in  which  such  teeth 
have  been  located  in  the  region  of  the  maxillary  antrum,  or  close  to 
the  orbit  or  buried  in  the  nasal  septum,  or  in  the  floor  of  the  nose, 
the  ramus  of  the  lower  jaw  and  in  other  unexpected  situations 
(Figs.  308  to  311.)     Good  has  been  accomplished  by  their  removal. 


Fig.  308. — -Impacted  teeth  in  adult  case.  Deciduous  teeth  crowned  through  error 
on  the  part  of  dentist.  Chronic  disease  in  this  region  finally  led  to  diagnosis  with  the 
ic-rays. 


Fig.  309.^ — Unerupted  left  cuspid  near  the  orbit  in  the  case  of  a  man,  aged  twenty-six 
years.     Maxillary  sinus  on  left  side  involved. 


Fig.  310. — Two  unerupted  cuspids  situated  in  the  palate  of  a  girl,  aged  twenty-two  years. 


560 


SURGERY  OF  THE  MOUTH  AXD  FACE 


Diagnosis. — In  examination  of  the  mouth,  the  number  of  teeth 
should  always  be  noted,  particularly  the  presence  or  absence  of  fully 
erupted  third  molars.  E^•ery  missing  tooth  should  be  accounted  for 
if  possible. 


Fig.  311. — Radiogram  of  the  mouth  of  a  young  woman,  aged  twenty  years,  showing 
an  impacted  third  molar.  In  this  case  severe  neuralgic  pain  in  the  head  was  relieved 
by  removal  of  the  impacted  teeth. 


Fig.  312. — This  shows  the  method  of  controlling  the  field  of  operation  in  extraction 
of  impacted  lower  teeth.  Gauze  held  between  tongue  and  jaw,  retractors  and  mouth 
gag  in  place,  and  the  svuface  of  the  impacted  lower  third  molar  exposed  ready 
for  extraction. 


MALFORMATIONS  OF  THE  MANDIBLE  561 

Radiograms  give  the  most  positive  and  also  the  most  accurate 
results  in  diagnosticating  teeth  that  may  be  embedded  in  the  jaws. 
A  sharp-pointed  stiff  probe  may  sometimes  be  passed  through  the 
more  or  less  softened  overlying  bone  and  once  the  enamel  crown  of  a 
tooth  is  encountered  the  difference  between  its  hard  smooth  surface 
and  bone  is  easily  recognized  by  the  sense  of  touch. 

Treatment. — Since  these  teeth  are  usually  beyond  the  reach  of 
dental  forceps,  their  surgical  removal  is  required.  This  may  be  accom- 
plished under  general  anesthesia,  or  by  conductive  anesthesia  through 
novocain  injected  at  the  mandibular  foramen,  by  chiselling  the  over- 
lying bone  or  cutting  it  out  with  a  dental  engine  but  sufficiently  to 
allow  the  tooth  to  be  grasped  with  forceps  and  withdrawn,  or  after 
being  uncovered  it  may  be  lifted  out  by  the  use  of  an  elevator  of 
suitable  form.  Not  infrequently  a  period  of  more  or  less  serious 
pain  follows  the  removal  of  deep-seated  impacted  teeth  because  the 
maxillary  nerves  may  be  temporarily  exposed.  Suitable  applications 
directly  to  the  end  of  the  tooth  socket  if  possible,  and  the  frequent 
use  of  antiseptic  mouth  washes  are  called  for  to  control  the  pain  and 
to  prevent  the  extension  of  infection  until  complete  relief  may  be 
given  by  the  healing  process  (Fig.  312). 

MALFORMATIONS    OF  THE  MANDIBLE  DUE  TO  ARRESTED    ] 
OR  PERVERTED  DEVELOPMENT. 

Prenatal  Tendency  to  Arrest  of  Maxillary  Development. — In  the 

absence  of  actual  deformity  such  as  described  on  page  577,  deficient 
maxillary  development  is  seldom  evidenced  at  birth.  It  cannot  be 
denied,  however,  that  some  individuals  are  born  with  a  tendency  to 
insufficient  maxillary  growth  which  becoming  intensified  by  post- 
natal nervous  and  metabolic  conditions  leads  to  many  defects  of  form 
in  this  region.  Figs.  313  and  314  show  congenital  malformation  of 
head  and  face  in  a  child  of  unusually  good  mentality  and  general 
physical  development  in  all  respects. 

Diseased  Conditions  as  Malforming  Factors. 

Endocrine  Disorders. — The  receding  chin  and  the  small  jaws  of  the 
so-called  hypopituitary  cases  and  the  prognathous  lower  jaw  attributed 
to  hyperpituitary  conditions,  as  well  as  the  abnormal  growth  of  the 
mandible  in  older  individuals  that  is  a  noticeable  symptom  of  acro- 
megaly, are  well  recognized  as  indications  of  effects  which  may  some- 
times be  due  to  other  developmental  derangements  of  this  character. 

Thickening  may  occur  as  a  result  of  inflammatory  conditions  and 
there  may  also  be  alteration  in  the  form  or  thickness  of  the  bone  from 
infectious  diseases  such  as  is  found  in  syphilis,  leontiasis  ossea,  arth- 
ritis deformans  and  other  similar  affections. 

Cysts  and  tumors  affecting  the  osseous  structures  of  the  jaws,  or  in 
surrounding  parts  may  cause  enlargement  or  absorption  and  thus  give 

VOL.  I — 36 


562 


SURGERY  OF  THE  MOUTH  AND  FACE 


rise  to  deformities.    The  loss  of  bone  through  necrosis  or  resections  is 
necessarily  followed  by  the  deforming  effect  of  scar  tissue  contraction 


Fig.  313. — Congenital  malformation  of  the  head  and  face  of  child  sixteen  months  old. 
Depression  in  the  frontal  region  on  the  right  side  and  a  corresponding  convexity  at 
the  occipito-parietal  junction  on  the  left  side.  Marked  convexity  in  the  malar  region 
on  the  right  side  with  corresponding  conca^-ity  on  the  left  side.  Left  ej'e  lower  than 
the  right;  nose,  superior  maxillarj-  bones  and  jaw  deflected  to  the  left. 


Fig.  314. — Same  child  shown  with  corrective  appliance  in  place.  Head  band  is 
adjusted  to  give  freedom  for  development  in  the  right  frontal  region  with  firm  com- 
pression over  the  excessively  developed  parts  of  the  head.  Pad  to  make  pressure  on 
right  malar  convexity  with  plate  in  mouth  to  which  the  arms  are  attached  from  which 
continuous  pressure  is  made  with  a  rubber  band  in  such  manner  as  to  tend  to  straighten 
the  face  and  reduce  the  deformity. 


MALFORMATIONS  OF  THE  MANDIBLE 


563 


or  disarrangement  of  the  bone  segments  by  disordered  muscular 
activity. 

Traumatic  Injuries. — The  lower  jaw  is  much  exposed  to  accidental 
injuries  which  cause  fractures,  and  deformities  frequently  follow 
imperfect  approximation  at  the  seat  of  fracture,  or  there  may  be  an 
alteration  in  the  outline  of  the  mandibular  arch  by  traumatism  without 
fracture. 

Loss  or  Deficiency  of  Normal  Physiologic  Activity  and  Antagonizing 
Mechanical  Influences. — ^The  illustrations  of  typical  forms  of  the 
mandible  in  cases  of  ankylosis  of  the  temporomandibular  articulation 
as  shown  in  Fig.  315,  and  the  deformities  of  the  lower  jaw  due  to  scar 
contraction  for  extensive  burns  in  early  childhood  in  Fig.  316,  serve 
to  emphasize  the  influence  of  both  these  types  of  factors  in  governing 
the  form  of  the  mandible. 


Fig.  315. — Bilateral  bony  ankylosis. 


Surgical  Methods  of  Correction. — When  projection  of  the  lower 
jaw  occurs  through  the  forward  tension  of  neck  scars  as  in  Fig.  315, 
or  from  any  other  influence  which  may  cause  an  increase  in  the  thickness 
of  the  anterior  portion  of  the  body  of  the  mandible  as  well  as  in  its 
length,  by  far  the  simplest  and  most  satisfactory  method  of  treatment 
is  to  expose  the  jaw  by  dissecting  free  the  overlying  soft  tissue  from 
an  incision  within  the  mouth,  and  turning  them  downward.  The 
exposed  portion  of  the  jaw  is  then  cut  off  in  a  slanting  direction  to  give 
the  effect  of  a  mental  process  when  the  parts  are  restored  to  position. 
Dental  bridge-work  attached  to  the  remaining  teeth  on  each  side  of  the 
restricted  portion  of  the  jaw  is  inserted  to  replace  the  teeth  thus  lost. 
Fig.  317  illustrates  the  result  of  this  kind  of  treatment. 


5C4 


SURGERY  OF  THE  MOUTH  AND  FACE 


Fig.  316. — Man,  aged  twenty-one  years,  who  was  burned  in  the  neck  when  three  j^oars 
old.     Scar  tissue  caused  unusual  length  and  thickness  of  lower  jaw. 


Fig.  317. — Same  man  showTi  shown  in  Fig.  316  after  operation.  The  lower  jaw  was 
excised  from  the  bicuspid  tooth  forward  and  a  mental  process  fashioned  out  of  the  thick 
jaw  bone  that  remained 


MALFORMATIONS  OF  THE  MANDIBLE  565 

When  the  angles  of  the  jaw  are  too  straight  there  is  often  occlusion 
of  the  molar  teeth  with  wide  separation  between  the  incisors.  In  young 
persons  this  defect  is  sometimes  reduced  by  force  applied  through 
suitably  adjusted  head  and  chin  pieces  but  in  older  persons  this  method 
of  treatment  is  impracticable.  By  the  extraction  of  a  bicuspid  tooth 
upon  each  side  and  the  removal  of  a  V-shaped  portion  of  bone  from  the 
sockets  of  these  teeth  on  both  sides  of  the  mouth  a  green-stick  fracture 
may  be  made  without  serious  consequence,  and  the  chin  brought  up- 
ward into  better  position.  The  parts  are  held  in  complete  fixation  by 
bands  attached  to  the  adjoining  teeth  with  connecting  bars,  nuts  and 
screws  as  previously  described.    (See  Figs.  320  and  321.) 


Fig.  318  Fig.  319 

Figs.  318  and  319. — Cast  of  the  face  of  a  young  man,  for  whom  the  author  removed 
a  section  from  one  side  of  the  lower  jaw,  as  shown  in  Fig.  318.  This  picture  is  shown 
through  the  courtesy  of  Dr.  Joseph  Eby,  of  Atlanta,  Ga.,  who  made  the  cast. 

The  shortening  of  the  jaws  by  this  treatment  is  sometimes  objection- 
able and  under  these  circumstances,  the  author  believes  that,  notwith- 
standing the  small  external  scars,  this  might  be  accomplished  more 
successfully  bj^  cutting  through  the  lower  border  of  the  jaw,  after 
making  an  incision  through  the  skin,  separating  the  intervening  tissues 
and  the  periosteum,  to  avoid  mouth  infection,  then  forcing  the  anterior 
teeth  into  contact  and  holding  them  in  position  with  suitable  splints 
attached  to  both  jaws. 

Defective  Tooth  Eruption.- — This  is  altogether  the  most  frequent  cause 
of  both  upper  maxillary  and  mandibular  defective  form.  Sometimes 
the  germs  of  teeth  are  missing  or  teeth  may  remain  embedded  in  the 
jaws  without  eruption,  or  be  erupted  on  the  lingual  or  buccal  aspects 
(within  or  without)  the  line  of  the  dental  arch;  or  their  early  extraction 
may  have  caused  the  same  effect.  Without  the  stimulation  of  develop- 
mental activity  that  is  induced  by  the  crowns  of  the  teeth  as  they 


566 


SURGERY  OF  THE  MOUTH  AND  FACE 


are  forced  into  their  normal  situations  in  the  course  of  natural  eruption 
the  maxillary  structures  do  not  grow  as  they  otherwise  would. 

Treatment. — The  effect  of  absence  or  disarrangement  of  the  teeth 
may  be  largely  overcome  by  the  well-known  methods  employed  by 
orthodontists.  ]\Iore  radical  surgical  procedures  should  not  be 
attempted  if  the  defect  can  be  o^■ercome  by  this  slower  but  very 
effective  and  in  the  end  probably  much  more  beneficial  plan  of  treat- 
ment. To  the  surgeon  who  is  usually  more  or  less  unfamiliar  with  the 
principles  of  orthodontia  the  following  outline  of  the  reasonable 
limitations  of  such  methods  mav  be  useful. 


Fig.  320. — Drawing  showing  the  deformity  of  the  jaws  of  the  young  man,  a 
cast  of  whose  face  is  shown  in  Fig.  335.  The  dotted  line  indicates  where  the  second 
bicuspid  tooth  and  a  section  of  bone  completely  through  the  jaw  was  removed  bj'  the 
use  of  a  saw  and  engine  bur. 

Marked  recession  of  the  chin  and  apparent  insufficiency  in  size  of 
the  lower  jaw  may  be  due  in  considerable  measure  to  distal  malocclusion 
so  that  the  teeth  of  the  lower  jaw  come  in  contact  with  the  upper  teeth 
farther  back  than  they  properly  should.  By  the  use  of  intermaxillary 
rubbers  and  in  various  other  ways  orthodontists  are  accustomed  to 
force  these  jaws  forward  with  marked  beneficial  affect.  ]Much  enlarge- 
ment of  the  dental  arch  with  corresponding  improvement  in  the  outline 
of  the  mandible  may  be  accomplished  by  the  use  of  orthodontic  appli- 
ances. Space  thus  secured  for  the  eruption  of  unerupted  teeth  in 
crowded  dental  arches  is  usually  followed  by  their  prompt  appearance. 
When  this  does  not  occur  further  growth  into  position  can  be  stimu- 
lated by  the  application  of  gentle  force.  The  general  growth  in  size 
of  the  lower  jaw  may  be  greatly  stimulated  by  steadily  applied  pressure 
from  suitable  appliances.  Beyond  this  the  grosser  deformities  require 
surgical  interference. 


MALFORMATIONS  OF   THE  MANDIBLE 


567 


The  maxillary  irregularities  which  may  be  prevented  or  improved  by 
treatment  are  necessarily  the  ones  about  which  surgical  interest  centers. 
The  possible  importance  of  endocrine  disorders  in  this  relation  must  be 
appreciated,  but  present  knowledge  of  this  form  of  therapy  is  too 
insufficient  to  warrant  definite  statements  with  regard  to  prophylactic 
measures  in  this  direction. 


Fig.  321. — -Shows  dra-ning  of  the  jaws  as  they  were  in  the  cast  illustrated  in  Figs. 
318  and  319  after  removal  of  a  second  bicuspid  tooth  and  complete  resection  of  the  jaw, 
the  approximation  of  the  bone  ends  and  fixation  with  an  appliance  attached  with  metal 
bands  cemented  to  the  teeth  and  adjusted  by  a  nut  tightened  upon  a  thread  cut  in  the 
bar  of  the  appliance.  In  most  cases  the  metal  band  shown  attached  to  the  molar  next 
to  the  point  of  excision  wovdd  be  better  attached  one  tooth  farther  back.  The  situation 
of  the  bands  must  necessarily  be  determined  by  the  condition  of  the  case. 

Prognathous  Lower  Jaw.— In  undertaking  surgical  treatment  for  the 
reduction  of  prognathism  of  the  loM^er  jaw  it  must  be  understood  that 
in  many  cases  this  deformity  is  not  due  to  an  excessively  large  lower 
jaw  so  much  as  it  is  to  an  arrested  development  of  the  upper  jaw  which 
is  usually  associated  with  a  contracted  upper  dental  arch  and  its 
invariably  accompanying  high  narrow  palatal  vault. 

Bilateral  Resections  to  Reduce  Prognathous  Loicer  Jaws. — ^The 
removal  of  a  segment  from  each  side  of  the  body  of  the  lower  jaw,  as 
performed  by  Blair  and  reported  by  Angle, ^  has  since  been  improved 


1  Blair's  Surgery  of  the  Diseases  of  the  Mouth  and  Jaws,  p  308. 


568  SURGERY  OF  THE  MOUTH  AXD  FACE 

by  Blair  who  has  perfected  a  method  of  performing  a  submucous  peri- 
osteal operation  for  the  removal  of  a  section  of  bone  on  each  side  of  the 
jaw  and  fixation  of  the  parts  with  a  splint  covering  the  cro^^Tls,  lingual 
and  buccal  surfaces  of  the  teeth,  made  in  three  sections  and  cemented 
before  the  operation  so  that  they  may  be  fastened  immediately  upon 
removal  of  the  bone  segments. 

Blair  believes  that  the  jaw  should  also  be  wired  near  the  lower 
border  to  give  additional  security.  Babcock  cuts  through  the  rami  of 
the  jaw,  slides  the  body  back,  and  fastens  it  in  this  position.  Harsha 
cuts  sections  from  the  angle  on  each  side,  and  thus  accomplishes  the 
necessary  shortening. 

Unfortunately  both  the  cases  reported  by  Babcock  and  Harsha 
appeared  to  the  author  to  have  been  of  such  character  that  much  better 
results  could  have  been  obtained  by  expansion  of  the  undersized  upper 
jaw  rather  than  by  reduction  of  the  lower  and  with  a  distinct  benefit  to 
respiration  and  health  by  such  expansion. 

Deformities  of  the  Jaw  due  to  Tumor  Growths  and  Tumor  Pressure. — 
When  the  outline  of  the  lower  jaw  has  been  deformed  by  tumor  growth 
and  tumor  pressure,  much  may  be  done  by  careful  separation  of  the 
overlying  periosteum,  and  the  removal  of  the  redundant  bone  structures 
sufficiently  to  restore  sjTtimetrical  outlines.  The  periosteum  is  then 
replaced.  Notwithstanding  the  unavoidable  oral  infectious  influences 
the  results  in  such  cases  are  usually  gratifying. 

Unilateral  Resection.^ — When  one  side  of  the  lower  jaw  is  longer  than 
the  other  it  can  be  reduced  ^^^th  immediate  improvement  in  the 
appearance  of  the  individual. 

The  author's  method  of  performing  this  operation  is  to  prepare  and 
cement  to  the  teeth  at  each  side  of  the  portion  to  be  revised,  a  splint 
made  of  metal  bands  attached  to  the  second  tooth  beyond  the  one 
next  to  the  incision  on  each  side.  These  are  connected  by  screws  and 
nuts  on  both  their  lingual  and  buccal  aspects.  When  the  section  of  bone 
is  resected,  the  nuts  are  tightened  until  the  bone  ends  are  held  firmly 
and  perfectly  in  contact.  The  result  is  absolutely  exact  and  there  is 
a  minimmn  of  postoperative  discomfort. 

In  the  same  way  the  author  also  lengthens  one  side  of  the  lower 
jaw  only,  in  this  case  the  turning  of  the  nuts  forces  the  several  bones 
apart,  and  holds  them  during  the  filling  in  of  bone  substance  between 
them.    Absolute  fixation  is  the  essential  thing  in  each  case. 

Extension  on  the  Lower  Jaw. — The  loss  of  a  section  of  bone  through 
necrosis,  resection,  accidental  injury,  gunshot  wounds,  etc.,  may 
require  extension  to  overcome  the  deformity  resulting  from  the  exces- 
sive retraction.  Bone  grafting  has  given  good  results  in  these  cases, 
as  described  on  page  643  and  illustrated  in  Figs.  452  to  462. 

The  Correction  of  Related  Nasal  and  Maxillary  Developmental 
Defects  by  Separation  of  the  Superior  Maxillae. — Etiology. — Deflec- 
tions of  the  nasal  septum,  contracted  nares,  high  narrow  palates  and 
irregular  dental  arches,  are  frequently  coincident  among  children  who 
present  the  usual  clinical  picture  of  adenoids,  enlarged  tonsils,  mouth 


MALFORMATIONS  OF  THE  MANDIBLE  569 

breathing  and  a  tendency  to  nasal  and  bronchial  diseased  conditions 
as  well  as  the  mental  and  nervous  characteristics  which  are  typical  of 
such  individuals.  This  leads  to  the  belief  that  there  is  an  impor- 
tant underlying  developmental  influence  which  is  accountable  for  the 
association  of  these  defects.  The  mechanical  effects  of  such  malfor- 
mations favor  the  wrong  appplication  of  the  force  of  muscular  activities, 
and  the  restriction  of  natural  function  which  must  also  be  considered 
in  determining  methods  of  surgical  correction. 

The  prenatal  influences  which  relate  to  heredity,  metabolism,  dis- 
eased conditions  of  the  parents  and  similar  factors  are  of  undoubted 
importance,  but  the  prophylaxis  which  might  be  influential  in  over- 
coming such  predisposition  necessarily  lies  outside  the  field  of  surgery. 

The  post?iatal  results  of  irregular  or  perverted  development  due  to 
abnormal  muscular  activities,  obstructions  of  the  upper  air  passages, 
and  similar  influences  require  operative  treatment  to  prevent  the 
extension  of  such  ill  effects,  and  to  restore  normal  functional  activities. 

The  influence  of  the  endocrine  organs  upon  the  form  and  character 
of  bodily  growth,  metabolic  changes,  and  nervous  and  mental  states,  as 
indicated  by  diseases  of  and  animal  experimentation  upon  the  hypoph- 
ysis, thyroid,  thymus  and  pineal  glands,  the  testes,  ovaries,  and 
other  members  of  this  group,  forms  the  basis  of  therapeutic  efforts  in 
this  direction.  There  appears  to  be  a  high  degree  of  susceptibility  to 
very  finely  balanced  chemical  influences  to  which  the  entire  endocrine 
organ  system  is  subject.  With  this  in  mind  one  can  better  understand 
how  irregular  dental  arches  and  high,  narrow  palates  may  primarily 
be  due  to  the  same  etiologic  influences  as  the  greater  deformities  noted 
in  acromegaly  and  other  diseases  showing  marked  variations  from 
normal  growth. 

Proof  of  the  effect  of  mechanical  restriction  of  growth  in  width 
across  the  palates  of  dogs  as  influencing  the  size  of  the  nares  the  form 
of  their  nasal  septa,  and  the  character  of  the  nasal  accessory  sinuses  is 
shown  in  Figs.  322  and  323.  The  results  were  identical  in  all  the  pups 
similarly  treated. 

The  dependence  of  dogs  upon  healthful  nasal  conditions  is  vital 
because  it  is  only  under  great  stress  that  any  air  can  be  inspired  through 
their  mouths.  For  this  reason  regularity  in  the  form  of  the  septum, 
nares,  and  nasal  accessory  sinuses  is  the  rule  among  all  such  animals. 

Symptoms  Shown  by  Pups  Similar  to  those  of  Human  Patients. — ^All 
the  pups  so  treated  developed  the  following  symptoms,  which  are 
identical  with  those  commonly  found  in  children  with  high,  contracted 
palates  and  irregular  upper  dental  arches,  viz.,  a  high  degree  of  sus- 
ceptibility to  infection,  which  was  evidenced  by  congested  bronchi 
and  lungs,  and  was  in  marked  contrast  to  the  usually  notable  resistance 
to  pathogenic  bacteria  of  the  bronchial  mucous  membrane  in  healthy 
dogs,  and  quite  in  accord  with  frequent  colds,  bronchitis,  and  tendency 
to  pneumonic  affections  that  are  characteristic  of  all  mouth-breathing 
children. 

Extreme  nervousness  was  also  similar  to  children  of  this  type.    The 


570 


SURGERY  OF  THE  MOUTH  AND  FACE 


tC^PI^ 


1^ 


CD  E 

Fig.  322. — Sections  of  head  of  puppy  six  months  old,  with  jaws  arrested  in  develop- 
ment across  the  palate  by  wiring  at  eight  weeks  old.  These  sections  when  compared 
with  those  of  a  normal  pup  shown  in  Fig.  323  show  plainly  the  contracted  effect  upon 
the  nares,  the  deviation  of  the  nasal  septum — especially  the  section  shown  in  C,  the  point 
at  which  the  wire  was  inserted  and  development  arrested.  The  enlarged  maxillary 
sinuses  are  also  evident  in  comparison. 


^\ 

i  A 

m^ 

V    ^ 

mm^iiqi 

V     ^va^SljK^ 

^r                   ^^v        Xj^Hj^yu^^^^^B 

\'% 

^^^^^S]       '  -^^|b 

C  D  E 

Fig.  323. — Control  pup,  same  age  as  Fig.  322,  upon  which  no  operation  was  performed. 


MALFORMATIONS  OF  THE  MANDIBLE  571 

nasal  accessory  sinuses  became  enlarged.  This  is  particularly  evident 
in  the  maxillary  sinuses  as  shown  in  Fig  321.  The  experiment  pups 
became  emaciated  and  were  not  nearly  so  large  and  fat  as  the  control 
pup,  although  given  the  same  food.  Making  all  due  allowance  for 
impure  breed,  there  was  still  evident  a  considerable  interference  with 
trophic  changes. 

Inasmuch  as  questions  of  heredity,  eugenics,  and  so-called  degener- 
ate tendencies  which  always  perplex  the  consideration  of  etiology  in 
human  subjects  of  this  character  may  be  ruled  out  in  dealing  with  dogs, 
the  importance  of  these  results  when  applied  to  the  treatment  of  chil- 
dren is  proportionately  increased.  Since  deflections  of  the  nasal  septum 
almost  invariably  result  in  dogs  and  among  children  when  there  is 
insufficient  breadth  across  the  upper  jaw,  with  a  corresponding  high 
narrow  palatal  vault,  obviously  the  first  step  toward  correction  of  this 
nasal  deflection  should  be  a  sufficient  restoration  in  the  width  of  the 
upper  dental  arch.  This  may  be  accomplished  as  indicated  in  Fig.  345 
by  separation  of  the  upper  maxillae  through  the  median  palatine  suture 
by  the  use  of  an  appliance  attached  to  the  teeth  on  each  side  of  the 
mouth  with  bands  cemented  into  place  and  connected  by  rigid  side 
bars  resting  against  the  lingual  sides  of  as  many  teeth  as  possible  on 
each  side  and  connected  by  a  combination  of  a  tube,  screw  and  nut 
across  the  most  contracted  portion  of  the  palate,  adjusted  so  that  when 
the  nut  is  turned,  pressure  will  be  exerted  to  force  the  maxillary  bones 
apart.  Turning  such  a  nut  twice  a  day,  morning  and  evening  suffi- 
ciently to  make  strong  pressure,  will  usually  spread  the  upper  maxillary 
bones  by  separation  through  this  median  palatine  suture  and  through 
their  attachment  to  the  nasal  processes,  the  nasal  bones  are  also  moved. 

By  this  procedure  all  the  necessary  intranasal  space  that  may  be 
required  for  comfortable  respiration  may  usually  be  secured  in  from 
ten  days'  to  two  weeks'  time  in  persons  up  to  approximately  thirty 
years  of  age.  Quite  naturally  the  younger  the  patients  are,  the  more 
easily  this  may  be  accomplished.  Occasionally  the  median  palatine 
suture  does  not  become  entirely  closed  until  after  middle  life  and  in 
such  cases  the  same  result  may  sometimes  be  obtained  for  persons  who 
are  more  than  thirty  years  old. 

The  Immediate  Surgical  Separation  of  the  Superior  Maxillary  Bones 
to  Widen  the  Nares  for  the  Improvement  of  Respiratory  and  Other  Condi- 
tions According  to  the  Author's  Operation. — The  day  before  the  operation 
is  performed  an  expansion  splint  is  cemented  to  the  teeth.  This  appli- 
ance is  in  all  respects  the  same  as  previously  described  for  the  slower 
method  of  non-smgical  rapid  maxillary  separation,  except  that  when 
possible  additional  bands  are  cemented  on  both  second  bicuspid  teeth 
and  hooks  to  slide  over  the  side  bars  to  give  greater  firmness. 

Under  general  anesthesia  the  upper  lip  is  raised  and  a  vertical  incision 
about  three-eighths  of  an  inch  long  in  the  median  line  above  and  between 
the  roots  of  the  central  incisor  teeth  is  carried  down  to  the  bone  close 
to  the  frenum  labialis  super ioris.  The  periosteum  is  then  slightly 
raised  on  each  side  of  the  incision  and  the  tissues  retracted  to  expose 
the  intermaxillary  suture. 


572 


SURGERY  OF  THE  MOUTH  AND  FACE 


A  fine  chisel  is  inserted  into  the  suture  at  this  point,  and  followed 
with  a  larger,  more  wedge-shaped  chisel.  A  few  blows  with  a  mallet 
forces  the  chisel  between  the  bones  and  by  tightening  the  screw 
of  the  mouth  appliance  the  separation  is  made  complete  (see  Figs. 
324  to  326). 

In  this  way  the  m  axillae  are  forced  apart,  carrying  with  them  the 
attached  nasal  bones.  The  result  is  a  direct  increase  in  size  of  the 
nares. 

The  almost  instantaneous  effect  of  forcing  the  maxillve  apart  after 
surgical  separation  appears  to  exert  a  more  pronounced  influence  in 
the  graver  types  of  cases  than  the  slower  method  of  depending  upon 
pressure  against  the  teeth  alone  as  in  non-surgical  rapid  expansion  of 
the  upper  dental  arch.    The  freer  bone  movement  thus  allowed  gives 


Fig.  324. — Shows  spliut  in  place  with  expansion  screw  bar  across  the  palate.  Vertical 
incision  as  made  above  and  between  the  roots  of  the  central  incised  teeth  down  to  the 
bone  at  the  intermaxillary  sutiire. 


less  tendency  to  flanging  of  the  teeth,  and  the  relation  of  intranasal 
enlargement  to  the  increased  width  across  is  proportionately  improved. 
With  the  restoration  of  nasal  respiration  and  the  cessation  of  mouth 
breathing  which  usually  follows  quite  naturally  when  the  nares  are  thus 
enlarged,  permanent  improvement  in  intranasal  conditions  almost 
invariably  results.  The  reduction  of  hypertrophic  conditions  and 
thus  gaining  freer  opening  of  the  ostea  of  the  nasal  accessory  sinuses, 
better  drainage  and  aeration  of  the  ethmoidal,  frontal,  sphenoidal  and 
maxillary  cells  and  sinuses  is  permitted.  This  may  give  far-reaching 
benefit,  and  there  is  usually  marked  tendency  toward  healthful 
disappearance  of  both  adenoids  and  enlarged  tonsils  under  these 
conditions. 


MALFORMATIONS  OF  THE  MANDIBLE 


573 


Fig.  325.— Chisel  at  the  intermaxillary  suture  being  driven  between  the  bones  by  gentle 

blows  with  a  mallet. 


Fig  326.— Turmng  the  nut  on  the  cross  bar  of  the  appliance  after  the  maxillary  bones 
have  been  partially  set  free  by  separation  through  their  intermaxillary  and  median 
palatine  sutures.  The  space  between  the  central  incisor  teeth  which  are  not  touched 
by  the  appliance  indicates  the  complete  accomplishment  of  the  separation  of  the  maxilla 
By  turmng  the  nut  during  the  first  few  days  after  the  operation  as  much  enlargement  as 
necessary  may  be  secured.  It  is  therefore  both  undesirable  and  unnecessary  to  apply 
much  force  with  the  expansion  screw  during  the  operation  whHe  the  patient  is  uncon- 
scious.    In^this  way  any  possible  danger  of  injury  to  the  teeth  is  avoided. 


574  SURGERY  OF  THE  MOUTH  AND  FACE 

Notwithstanding  the  generally  recognized  importance  of  diseased 
tonsils  as  foci  of  infection  which  may  lead  to  serious  though  remotely 
situated  disease,  many  operators  feel  that  tonsillectomy  should  not  be 
performed  except  for  good  and  sufficient  reasons  as  in  the  presence  of 
actual  disease,  evidenced  by  repeated  attacks  of  tonsillitis  or  some 
equally  grave  disturbance.  The  question  of  precedence  in  determining 
whether  the  adenoids  and  tonsils  should  first  be  removed  and  then  the 
nares  widened,  or  the  nares  given  opportunity  for  the  natural  restora- 
tion of  healthful  tonsillar  conditions  before  tonsillectomy  and  adenec- 
tomy  are  performed,  is  sometimes  difficult  to  decide.  There  can, 
however,  be  no  question  but  that  the  future  health  of  both  nose  and 
pharynx  depends  upon  restoration  of  sufficient  space  to  permit  the 
permanent  establishment  of  free  nasal  respiration. 

When  the  upper  maxillse  are  spread  apart  and  the  intranasal  space 
increased,  the  septal  straightening  through  its  natural  resiliency  is 
frequently  so  marked  as  to  make  correction  of  the  deflection  by 
resection  quite  unnecessary,  but  when  this  deformity  is  too  great  or 
of  such  long  standing  that  complete  relief  cannot  be  given  in  this  way, 
then  the  usual  operation  for  resection  must  be  performed.  Even 
though  operation  upon  the  septum  may  be  necessary,  the  extent  of  the 
required  resection  will  be  much  less  and  the  operative  conditions  much 
more  favorable  to  a  permanent  benefit  after  maxillary  expansion  has 
been  previously  employed. 

The  Indications  of  a  Distinctive  Governing  Developmental  Influence. — 
Among  patients  referred  to  me  by  rhinologists  for  maxillary  expan- 
sion to  correct  pathological  states  coincident  with  contracted  nares 
and  deflected  nasal  septa,  who  have  also  high,  narrow  palatal  vaults, 
irregular  dental  arches,  adenoids,  enlarged  tonsils,  and  typical  mouth- 
breathing,  I  have  found  upon  more  general  examination  that  in  a  large 
number  of  cases  their  backs  were  also  irregularly  formed,  one  shoulder 
blade  being  larger  than  the  other  and  one  of  them  higher  or  lower,  with 
atendency  to  curvature  of  the  spinal  column.  The  hands  and  feet  also 
quite  frequently  showed  irregularities.  In  the  hand,  palmar  wasting 
and  an  enlarged  thumb  were  sometimes  conspicuously  evident.  One  side 
of  the  face  was  sometimes  found  to  be  more  developed  than  the  other, 
the  unilateral  asymmetry  being  quite  outside  of  that  which  might  be 
expected  from  irregular  teeth  alone.  These  features  bore  a  striking 
resemblance  to  the  recognized  indications  of  muscular  dystrophy, 
which  in  its  progressive  form  leads  to  weakness  and  actual  loss  of 
usefulness  in  muscles  of  the  affected  regions,  and  which  may  end  in 
death,  or  in  some  mysterious  way  become  arrested,  leaving  the  muscles 
in  a  state  of  partial  usefulness. 

Following  the  maxillary  separation  by  rapid  expansion  in  individuals 
presenting  the  clinical  picture  I  have  described,  there  is  manifested 
in  addition  to  the  relief  of  freer  nasal  respiration  and  better  nasal 
accessory  sinus  drainage,  an  influence  upon  nerve  tension  that  tends 
to  bring  about  a  general  improvement  in  nervous  conditions.  This  is 
many  times  an  active  factor  in  helping  to  overcome  a  tendency  to 


MALFORMATIONS  OF   THE  MANDIBLE  575 

habits  such  as  winking  of  the  eyeh'ds  or  similar  involuntary  acts  that 
simulate  the  beginning  of  spasmodic  affections.  An  almost  innumer- 
able list  of  other  evidences  of  unstable  nervous  tendencies  could  be 
described  if  necessary.  Notable  examples  of  these  are  referred  to  in 
connection  with  the  illustrations.  The  dulness  and  apathy  which  are 
not  only  pathognomonic  of  mouth-breathers,  but  of  serious  nervous 
states  as  well,  seem  to  disappear.  These  patients  do  better  in  their 
school  or  college  work  after  this  treatment  than  before. 

Increased  growth  or  weight  indicates  that  the  centers  governing 
trophic  changes  have  been  stimulated.  How  much  of  all  this  progres- 
sive effect  the  improved  respiration,  unaided  by  any  other  factor, 
may  be  responsible  for,  it  is  difficult  to  say,  but  it  is  reasonable  to 
assume  that  the  vital  and  final  influence  lies  much  deeper.  In  a  pro- 
phylactic sense  there  is  almost  unlimited  opportunity  for  expansion 
in  the  region  of  the  jaws  and  face  to  give  greater  developmental  free- 
dom at  the  base  of  the  skull  in  younger  children,  thereby  favoring  more 
perfect  conditions  pertaining  to  the  large  foramina,  through  which 
the  cranial  nerves  and  accompanying  vessels  must  emerge,  and  com- 
pression of  which  under  disturbed  conditions  might  be  favored  by 
imperfect  development. 

As  is  well  known,  children  who  are  mouth-breathers  because  of 
adenoids,  enlarged  tonsils,  or  arrested  or  perverted  nasal  development, 
are  frequent  sufferers  from  coughs,  colds,  and  other  evidences  of  infec- 
tious processes  in  this  region.  The  same  is  true  with  older  persons  in 
corresponding  degree. 

With  the  development  of  knowledge  pertaining  to  the  vegetative 
nervous  system  and  the  far-reaching  effect  upon  physiological  and 
pathological  phenomena  that  are  controlled  by  the  counteracting 
adjustment  of  the  balance  between  the  sympathetic  and  vagus  systems, 
much  that  has  hitherto  been  etiologically  and  pathologically  obscure 
is  rapidly  coming  to  be  better  understood,  and  this  is  particularly  true 
of  treatment  by  jaw  expansion. 

It  is  well  known  that  "The  vagus  system  supplies  the  large  glands 
of  the  abdominal  cavity,  the  lower  two-thirds  of  the  esophagus,  the 
stomach,  and  the  intestines  as  far  as  the  descending  colon.  The  sym- 
pathetic supplies  the  tract  from  one  end  to  the  other. 

"The  ganglion  cells  of  the  walls  of  the  intestines  control  this  move- 
ment of  the  intestinal  organs,  but  the  sympathetic  and  the  vagus 
exercise  the  regulatory  functions  of  acceleration  or  inhibition. 

"The  vagus  nerve  through  its  depressor  nerve  exercises  an  inhibitory 
action  on  the  heart,  while  the  sympathetic  through  its  acceleration 
nerves  has  acceleration  functions.  In  the  digestive  tract  this  is  reversed : 
The  vagus  accelerates.    The  sympathetic  inliibits." 

Higler^  calls  attention  to  the  important  significance  of  the  existence 
of  the  following  structiu-es :  (a)  Ciliary  ganglion  lying  in  the  posterior 
part  of  the  orbit  which  supplies  the  sphincter  iridis  and  the  ciliary 

1  Vegetative  Neurology,  Jour.  Ment.  and  Nerv.  Dis. ;  translation  by  Walter  Max 
Kraus,-  New  York. 


576 


SURGERY  OF  THE  MOUTH  AXD  FACE 


muscle;  (b)  the  sphenopalatine  ganglia  lying  on  the  pterygopalatine 
fossa  which  supplies  the  lacrimal  gland  and  the  nmcous  glands  of  the 
nasopharynx;  (c)  the  otic  ganglia  lying  under  the  foramen  ovale  which 
supplies  the  parotid  gland;  (d)  the  submaxillary  and  sublingual  ganglia 
which  supply  the  corresponding  glands;  (c)  the  automatic  ganglia  (the 
bulbar  part  of  the  vagus  domain)  which  lie  in  organs  and  which  supply 
the  glands  and  muscles  of  the  trachea,  the  heart  muscle,  and  the  gastro- 
intestinal tract  from  the  mouth  to  the  descending  colon;  (/)  the 
ganglion  mesentericum  inferium,  hypogastricum,  and  hemorrhoidale 
which  lie  in  the  upper  and  lower  parts  of  the  pelvis,  supplying  the 
muscles  and  glands  of  the  descending  colon,  the  sigmoid,  the  anus 
the  genital  apparatus,  and  the  bloodvessels  belonging  thereunto. 

The  Immediate  Effect  of  Maxillary  Separation. — ^The  patients  them- 
selves almost  in\ariably  recognize  the  difference  in  nasal  breathing, 
and  this  improvement  occurs  when  other  evidences  indicate  that  the 
nose  has  been  widened  and  the  volume  of  air  correspondingly  increased 
at  each  inhalation.  The  degree  of  the  change  is  naturally  governed 
by  the  condition  of  the  nasal  mucous  membrane,  which  may  be  rapid 
or  slow  or  variable  in  its  response. 


Fig.  327. — Skiagram  of  the  mouth  of  a 
girl,  aged  eight  years,  showing  appUance  in 
place  but  before  pressure  has  been  apphed 
—taken  June  29,  1913. 


Fig.  328.— The  same  mouth  July  29, 
1913.  This  result  might  have  been  secured 
much  earlier  except  for  delays  which  oc- 
curred by  the  patient's  being  out  of  the 
city. 


Patients  also  commonly  report  feeling  the  effect  of  pressure  high 
up  in  the  nasal  and  maxillary  regions  when  the  nut  is  turned  tightly 
after  the  maxillae  have  beer  separated. 

Rhinologists'  examinations  almost  invariably  disclose  that  there 
has  been  an  immediate  enlargement  of  the  breathing-space.  Practi- 
cally all  such  patients  in  my  practice  are  referred  to  rhinologists  for 
examination  as  soon  as  the  incisors  are  moved  apart  sufficiently  to 
warrant  the  belief  that  there  has  been  a  noticeable  change  within  the 


nose. 


The  .r-ray  invariably  gives  pictures  such  as  Figs.  327  and  328. 

Fig.  330  shows  the  radiograph  of  the  central  portion  of  the 
palate  of  a  man,  aged  twenty-eight  years,  whose  upper  maxillse  were 
widely  separated  because  of  marked  intranasal  deformity  and  nasal 


HARELIP 


577 


disease  associated  with  pathologic  conditions  of  the  nasal  accessory- 
sinuses  and  a  debilitated  general  state  which  precluded  active  physical 
effort.  All  these  symptoms  have  since  almost  entirely  disappeared. 
This  radiograph,  taken  two  years  after  his  mouth  was  expanded, 
shows  a  dark,  broad  line  which  seems  to  indicate  that  bone  had  been 
developed  along  the  line  of  the  interspace  between  the  bones  sepa- 
rated through  the  median  maxillary  suture,  just  as  one  would  be  led  to 
expect  would  occur  under  any  other  similar  conditions. 


Fig.  329 


Fig.  330 


Fig.  329. — Skiagram  of  the  mouth  of  a  boy,  aged  twelve  years,  who  was  a  chronic  suf- 
ferer from  hay  fever,  headaches,  bronchitis,  and  general  nervous  conditions,  particularly 
noticeable  in  winking  of  the  eyelids.  Marked  improvement  in  all  these  symptoms 
followed  widening  of  his  upper  dental  arch  in  July,  1912.  The  skiagram  of  his  palate 
was  taken  January  11,  1913.  The  thick  black  line  along  the  line  of  the  median  palatine 
suture  seems  to  indicate  new  bone  formation  in  that  region.  During  these  six  months 
his  growth  in  height  was  increased  two  and  three-quarter  inches. 

Fig.  330. — Skiagram  of  the  palate  of  a  young  man,  aged  twenty-eight  years,  for  whom 
wide  separation  of  the  median  palatine  suture  was  performed,  with  great  benefit  to  nasal 
and  general  pathologic  conditions;  taken  two  years  afterward.  The  thick  dark  line 
shown  where  new  bone  had  formed  in  the  line  of  the  formerly  separated  median  pala- 
tine suture,  proves  that  the  osteogenetic  layer  of  the  palatal  periosteum  does  become 
active  under  these  conditions  and  that  new  bone  formation  results. 


HARELIP. 

Development. — At  approximately  the  third  week  the  mandibular 
arches  of  the  fetus  appear.  In  due  course  from  these  the  maxillary 
processes  grow  forward  and  the  olfactory  pits  of  the  frontonasal  pro- 
cesses appear  to  prepare  for  the  formation  of  the  nostrils  at  about 
the  fifth  week.  The  globular  processes  unite  to  form  the  philtrum  of 
the  upper  lip,  and  when  joined  to  the  lateral  nasal  processes  they  also 
give  rise  to  the  alse  nasi.  By  fusion  of  the  globular  processes  at 
approximately  the  eight  week  the  upper  lip  is  formed. 

Division  between  the  nose  and  mouth  occurs  through  development 
of  the  premaxillary  portion  of  the  palate  from  the  globular  processes 
and  the  remainder  of  the  palate  from  the  maxillary  processes.  Extend- 
ing inward  toward  the  central  line  and  backward  the  complete  forma- 
tion .  of  these  parts  is  accomplished  and  fusion  of  the  premaxillse 
brought  about  at  approximately  the  ninth  week.  Thus  it  may  be 
seen  that  the  failure  of  union  in  any  of  these  parts  would  give  rise  to 
the  different  forms  of  harelip  and  cleft  palate  (Fig.  331). 

VOL.  I — 37 


578 


SURGERY  OF  THE  MOUTH  AXD  FACE 


Etiology. — The  same  influences  that  pertain  to  other  developmental 
defects  are  also  potent  in  the  causation  of  these  deformities.    Hered- 


FiG.  331. — Section  through  the  head  of  a  human  embrjo  at    approximately  the 
fifth  week.     (Latham.) 


Fig.  332. — Double  development  of  the  nasal  septum,  with  central  groove  through 
nose  and  median  fissure  of  the  upper  lip  and  palate. 

ity,  consanguinity,  syphilis,  imperfect  metabolism,  endocrine  organ 
disorders,  and  pathological  affections  of  the  female  generative  organs 


HARELIP 


579 


through  misplacement,  defective  form  or  mflammatory  conditions, 
and  mistable  nervous  states  may  each  be  entitled  to  consideration  as 
predisposing  or  direct  factors. 

The  exact  importance  of  hereditary  influences  in  this  regard  is  difH- 
cult  to  determine.  The  family  histories  of  many  hundreds  of  these 
cases  that  have  come  under  the  author's  observation  when  considered 
in  a  general  way  seem  to  show  only  a  small  percentage  Capproximately 
10  per  cent.)  in  which  it  could  be  determined  that  blood  relations  were 
similarly  affected;  but  in  the  southern  States,  where  family  histories 
are  more  easily  recorded  and  where  consanguinity  might  also  be 
expected  to  be  a  notable  factor  because  of  the  somewhat  frequent 
intermarriage  of  more  or  less  directly  related  individuals,  heredity 
appears  to  be  influential  much  more  frequently  than  among  children 
born  in  the  northern  and  western  States. 


Fig.  333. — Complete  bilateral  fissure  (coloboma)  of  face.     (Guersant.) 

Varieties. — The  most  common  forms  of  lip  fissure  are  single  harelip, 
in  which  there  is  a  division  on  the  right  or  left  side  of  the  median  line, 
and  doiihle  cases  with  fissures  on  both  sides  of  the  upper  lip  (Figs. 
334,  336,  338,  and  339). 

Single  median  fissures  sometimes  occiu-  (Fig.  332)  and  either  single 
or  double  fissures  may  extend  completely  through  the  face  up  to  the 
orbits  (Fig.  333),  or  be  associated  with  cyclops  and  other  extensive 
deformities.  Fissm"es  of  the  lower  lip  and  jaw  appear  less  frequently 
than  upper  lip  defects,  and  in  rare  instances  there  is  a  cleft  chin  due 
to  failure  in  the  union  of  the  two  inferior  maxillary  arches.  The 
precarious  condition  of  infants  with  extensive  facial  fissures  usually 
renders  operative  assistance  a  matter  of  such  great  uncertainty  as  to 


580 


SURGERY  OF  THE  MOUTH  AND  FACE 


be  almost  useless.  Attempts  in  this  direction  should  be  by  extension 
and  adaptation  of  the  methods  employed  in  the  treatment  of  more 
simple  cases. 


Fig.  334. — Single  harelip  (2d  degree). 


Fig.  335. — The  same  child  as  shown  in 
Fig.  334  after  operation.  , 


Fissures  of  the  lower  lip  require  essentially  the  same  treatment  as 
upper  lip  fissures  in  reverse  order.  Failure  of  union  in  the  median  line 
of  the  lower  jaw  may  require  that  the  bones  be  united  to  permit  con- 
tinuous growth,  and  later  treatment  in  the  form  of  extension  and 
expansion  of  the  lower  jaw  by  the  use  of  appliances  to  restore  its  s^in- 


FiG.  336. — Single  harelip  (3d  degree). 
In  this  case  there  was  a  cleft  through 
both  hard  and  soft  palates. 


Fig.  337. — Same  child  as  shown  in  Fig. 
336  after  both  lip  and  palate  fissuies  have 
been  closed  by  operation. 


metrical  appearance  and  usefulness.  The  growth  and  form  of  such  a 
jaw  may  be  much  improved  by  the  properly  directed  pressure  of 
orthodontic  and  orthopedic  methods. 


HARELIP 


581 


Harelips  are  usually  described  as  of  first  degree  when  the  fissure 
involves  only  a  portion  of  the  lip,  second  degree  when  the  cleft  includes 
the  entire  length  of  the  lip  from  the  prolabium  to  the  nose,  and  third 
degree  those  in  which  wide  fissures  extend  completely  through  the  lip 
and  include  also  the  alveolar  and  palatal  bone  structures. 

Congenital  Lip  Scars  may  occur  on  one  or  both  sides  of  the  lip.  Such 
white  marks  usually  follow  the  lines  of  harelip  fissures  and  may  or 
may  not  be  associated  with  prolabial  defects.  Notwithstanding  their 
sunple  appearance  such  scars  are  among  the  most  difficult  of  all  lip 
imperfections  to  remove  with  good  cosmetic  effect. 


Fig.  338. — Infant  with  single  harelip 
(3d  degree)  and  -n-ide  fissure  through  both 
hard  and  soft  palates,  showing  character- 
istic deformity  of  nose  and  mouth. 


Fig.  339. — Same  baby  at  eight  months 
of  age,  after  lip  and  hard  palate  have  been 
closed  as  described. 


The  Time  and  Character  of  the  First  Operation  When  Both  Lip  and 
Palate  are  Involved. — ^The  right  settlement  of  this  distressing  question 
is  a  matter  of  vital  importance  to  the  parents  of  such  a  child  and  also 
to  the  physician  in  charge  of  the  case.  There  are  many  reasons  why 
good  results  can  be  secured  by  closing  the  lip  first  and  the  palate 
afterward  that  cannot  be  obtained  by  reversing  this  order  of  procedure, 
or  in  attempting  to  close  both  lip  and  palate  at  the  same  operation. 
When  both  are  closed  simultaneously  it  is  impossible  to  properly  care 
for  either  after  operation,  therefore  the  palate  must  be  neglected  to 
prevent  injury  to  the  lip,  and  the  lip  is  constantly  in  danger  of  infec- 
tion from  the  palate.  Figs.  357  and  361  illustrate  some  of  the  disastrous 
results  of  this  treatment. 

Principles  of  Cheiloplasty  and  Staphylorrhaphy. — The  essential  fea- 
tures of  harelip  and  cleft  palate  treatment  may  be  summed  up  under 
two  heads. 

The  Preservation  of  Natural  Anatomical  Relation  and  Fostering 
Normal    Development. — When   a   single   fissure   extends   completely 


582  SURGERY  OF  THE  MOUTH  AND  FACE 

through  the  hard  palate,  the  alveolar  ridge  and  the  lip  surface  it  is 
usually  deflected  to  the  right  or  left  in  the  line  of  the  premaxillary 
suture.  (A  division  straight  through  the  central  line  between  the 
premaxillse  is  of  rare  occurrence.)  The  premaxilla  is  thus  projected 
forward  and  to  the  opposite  side  with  corresponding  deformities  of 
the  nasa;l  septum,  the  triangular  cartilage,  the  nose,  and  the  ala  on 
the  affected  side.  If  associated  with  double  harelip  the  premaxilla 
is  more  or  less  completely  free  from  lateral  maxillary  attachment,  and 
through  the  lack  of  restraining  muscular  influences  projects  forward 
and  upward.  The  result  of  this  invariably  leads  to  insufficient  devel- 
opment of  the  columna  of  the  nose  and  an  excessive  growth  of  the 
nasal  septum  and  the  vomer  with  flatness  of  the  cartilaginous  wings 
of  the  nose  upon  both  sides.  The  segments  of  the  upper  jaw  even  at 
birth  contain  the  germs  of  nearly  all  of  both  the  deciduous  and  per- 
manent sets  of  teeth.  It  is  obvious  then  that  to  preserve  the  form  of 
the  palate  and  the  dental  arches  upon  which  both  cosmetic  eft'ect  and 
speech  depend,  these  parts  should  be  brought  into  natural  relation  as 
closely  as  possible  (Fig.  340). 


Fig.  340. — Infant  with  double  harelip;  shows  characteristic  projection  of  the  premaxilla, 
and  philtrum  of  the  upper  lip. 

Operative  Methods. — A  comprehensive  idea  of  the  management  of 
harelip  and  cleft  palate  cases  may  best  be  given  by  consideration  of 
the  class  of  cases  in  which  the  fissure  extends  completely  through  both 
hard  and  soft  palates,  the  alveolar  ridge  and  lip. 

First  Aid. — If  operation  cannot  be  performed  immediately  then 
as  soon  as  possible  after  birth  a  strip  of  adhesive  plaster  should  be 
placed  across  the  lip  fissure  as  shown  in  Fig.  341.  This  should 
be  narrow  where  it  crosses  the  lip  and  wide  at  each  end  to  give 
suflficient  skin  resistance.  It  should  be  tight  enough  to  insure  tension, 
so  that  when  this  is  intensified  as  the  child  cries  or  smiles  it  will  reduce 


HARELIP 


583 


the  width  of  the  fissure.    Immediate  control  of  the  parts  in  this  way 
prevents  increase  of  the  nasal  deformity  and  further  widening  of  the 


Fig.  341. — Same  infant  as  in  Fig.  340  with  adhesive  strip  adjusted  to  reduce  the 
deformity  as  described  in  the  test. 

lip  and  palate  fissures  by  adverse  muscular  action.  The  same  muscles 
are  thus  employed  to  reduce  instead  of  increase  these  deformities. 
The  child  breathes  better  from  the  beginning  and  can  take  nourish- 
ment more  advantageously.  Figs.  342  and  343  show  how  much  may  be 
accomplished  in  a  short  time  by  such  fixation. 


Fig. 


342. — Same  infant  as  in  Figs.  340  and  341.    Front  view  before  operation  shows  the 
benefit  derived  from  wearing  the  adhesive  strip  for  about  ten  days. 


Age  of  Harelip  Operation. — ^The  conditions  which  must  govern  the 
determination  of  the  age  at  which  harelip  operation  should  be  done  are 


584 


SURGERY  OF  THE  MOUTH  AND  FACE 


opportunity  and  the  condition  of  the  child.  Whenever  possible  the 
lip  should  be  closed  upon  the  day  of  birth  or  at  the  earliest  possible 
time  that  circumstances  will  permit.  Decision  in  this  respect  must 
be  subject  to  the  condition  of  the  health  of  the  infant.  It  may  be 
necessary  to  perform  an  immediate  operation  in  order  to  improve  its 
ability  to  take  nourisliment  thus  increasing  the  possibility  of  improved 
health,  or  the  child's  condition  may  be  so  precarious  as  to  preclude 
operation  of  any  kind  until  its  strength  may  become  sufficient  to 
insure  better  operative  resistance.  In  newborn  infants  this  is  seldom  a 
matter  of  great  importance,  but  after  the  first  few  weeks,  when  there 
may  be  evidence  of  malnutrition  and  bottle-feeding  difficulties,  it  is 


Fig.  343. — The  author's  method  of  single  harelip  operation.   Fissure  borders  denuded  and 
split:  the  prolabium  flaps  prepared  for  suturing;  the  first  control  suture  in  place. 


sometimes  an  exceedingly  difficult  matter  to  decide.  Good  results 
can  be  secured  at  any  time  within  the  first  two  or  three  months  and 
even  at  six  months  old  or  later,  although  such  delay  should  be  avoided 
if  possible. 

Position  During  Operation. — The  arms  are  bound  close  to  the  sides 
of  the  body  bj"  wTappings  which  may  be  warm  but  not  too  tight.  A 
warm-water  bottle  under  the  legs  and  buttocks  gives  necessary  heat 
sustenance,  reduces  tendency  to  shock,  and  rests  that  portion  of  the 
body.  A  pillow  or  small  sand-bag  mider  the  shoulders  causes  the  head 
to  drop  backward  and  gives  a  better  view  of  the  field  of  operation. 
This  position  also  reduces  the  likelihood  of  blood  inspiration.  After 
proper  cleansing  of  the  skin  surfaces  and  the  nose  and  mouth,  a  strip 


HARELIP  585 

of  folded  gauze,  such  as  is  used  for  gauze  drains  is  packed  lightly  into 
the  fissure  and  loosely  placed  between  the  jaws  in  such  manner  that 
it  may  not  cause  distortion  of  the  external  parts  or  interfere  with  the 
operation,  but  may  check  the  flow  of  blood  into  the  throat  and  still 
be  sufficiently  loose  to  permit  the  free  inspiration  of  air. 

Fixation  of  the  Nasal  Septum  and  Ala. — The  author  carries  a  silk- 
worm-gut suture,  with  a  silver  splint  attached  to  it,  through  the  nasal 
septum,  beneath  the  cartilaginous  wing  of  the  nose  out  upon  the  cheek 
close  to  the  nasolabial  angle,  where  it  is  fixed  by  the  use  of  a  silver 
plate  fastened  with  a  perforated  shot  clamped  on  the  wire.  To  prevent 
irritation  from  the  silver  plate  a  strip  of  adhesive  plaster,  with  a  hole 
in  the  center,  to  permit  the  wire  to  pass  through  it,  is  first  laid  upon 
the  skin  surface.  This  combination  of  splint  and  suture  serves  to  hold 
the  parts  in  the  right  position.  It  also  relieves  tension  during  the 
healing  of  the  wound  and  is  very  effective  in  aiding  the  control  of 
hemorrhage  during  the  operation. 

Lijp  Compression  Clamps.— Heniorrhsige  from  the  coronary  arteries 
of  the  lip  is  controlled  by  simple  spring  clamps  that  are  easily  and 
quickly  adjusted.  Before  they  are  placed,  however,  it  must  be  remem- 
bered there  is  often  a  great  difference  in  both  the  length  and  thickness 
of  the  lip  tissues  upon  each  side  of  the  fissure.  It  is  therefore  important 
that  approximate  measurements  be  made  and  the  length  of  the  inci- 
sion estimated  upon  the  outline  of  the  parts  before  they  are  distorted 
in  any  way  by  the  adjustment  of  clamps. 

Lines  of  Incision.— The  points  at  which  the  skin  incision  must  begin 
and  end  should  be  fixed  by  the  attachment  of  small  forceps.  Allow- 
ance should  be  made  at  the  border  of  the  skin  and  prolabium  so  that 
the  length  of  the  lip  in  the  line  of  the  incision  may  be  such  as  to  give 
a  symmetrical  outline  to  the  mouth.  In  making  this  estimate  there 
are  a  few  considerations  that  are  of  vital  importance :  If  the  line  of 
the  lip  approximation  when  completed  be  ever  so  little  too  long  it 
will  result  in  a  tendency  to  draw  downward  and  inward.  As  the  child 
grows  older  this  will  cause  the  lip  to  become  unusually  long,  and  will 
bring  about  the  unsightly  rabbit-like  appearance  which  may  be  noted 
in  Figs.  365  to  367.  If,  on  the  other  hand,  the  incisions  are  not  carried 
sufficiently  far  and  thus  do  not  include  the  requisite  amount  of  lip 
surface,  the  lip  at  this  point  will  be  short  and  the  unsightly  notch 
that  is  so  often  associated  with  these  cases  will  mar  the  effect  of 
the  operation.  It  is  failure  in  this  respect  more  often  than  scar 
contraction  that  leads  to  this  form  of  postoperative  lip  defect. 
The  incision  in  every  case  should  be  as  simple  in  form  as  possible. 
Unfortunately  the  literature  of  this  subject  supplies  innumerable 
descriptions  of  more  or  less  complicated  methods  of  making  incisions 
to  adjust  malformed  lips  of  this  character.  The  illustrations  that 
accompany  them  are  often  very  elaborate,  but  the  author's  experience 
with  many  hundred  of  these  cases  warrants  the  statement  that  the 
greatest  possible  benefit  can  only  be  secured  in  proportion  to  the 
simplicity  and  direct  purpose  of  the  lines  of  incision.    Any  adjust- 


586  SURGERY  OF  THE  MOUTH  AND  FACE 

ment  of  the  lip  fissure  borders  which  contemplates  even  the  slightest 
degree  of  malposition  of  important  muscular  fibers  no  matter  how 
smooth  the  eft'ect  may  be  when  shown  on  paper  can  only  result  in 
more  or  less  permanent  distortion  of  the  parts.  Even  though  the  lip 
tissue  may  be  scant  and  the  fissure  wide  and  for  these  reasons  the  imme- 
diate eftect  of  the  harelip  operation  less  perfect  than  might  be  desired 
if  the  cartilaginous  nasal  structures  have  been  properly  restored,  and 
the  sjTnmetrical  alignment  of  the  lip  muscles,  particularly  the  orbi- 
cularis oris,  probably  adjusted  later  development  will  have  a  ten- 
dency toward  normal  lines  which  will  bring  about  great  improvement 
as  the  child  gets  older;  whereas,  a  more  perfect  immediate  result  in 
the  case  of  an  infant  with  imperfect  muscular  approximation  will 
result  in  a  tendency  to  continued  exaggeration  of  the  defect.  In  sin- 
gle harelip  cases  the  incision  should  be  begun  sufficiently  high  up  in 
the  direction  of  the  nose  to  give  suitable  outline  to  the  naris  when 
the  parts  are  brought  together.  This  line  should  continue  downward 
in  such  direction  as  to  meet  the  vermilion  border  of  the  prolabium  at 
exactly  the  right  points  on  each  side  of  the  fissure,  so  that  when 
brought  together  the  lip  will  be  the  required  length.  The  knife  is  car- 
ried completely  through  the  lip  in  a  slanting  direction  with  the  point 
toward  the  fissure  on  each  side.  The  tissue  thus  saved  will  tend  to 
increase  the  thickness  of  the  lip  and  prevent  depression  along  the  line 
of  approximation.  At  the  prolabial  border  the  resulting  flap  when 
turned  downward  is  held  with  tissue  forceps  and  the  knife  made  to 
cut  toward  the  fissure  close  to  the  skin  which  is  included  in  the  flap 
but  with  a  sufficient  margin  of  mucous  membrane  to  insure  the  com- 
plete removal  of  every  portion  of  skin  in  this  situation.  One  of  the 
most  common  postoperative  defects  is  caused  by  the  inclusion  of  a 
portion  of  skin  in  the  mucous  membrane  of  the  lip.  To  give  addi- 
tional thickness,  both  sides  of  the  lip  are  split  longitudinally  through 
the  central  portion  of  the  raw  surface  of  the  freshened  border.  This  is 
very  necessary  at  the  prolabial  border  of  the  lip,  as  it  gives  additional 
thickness  at  this  point  to  preserve  the  natural  form  of  the  lip  and 
frees  the  mucous  membrane  sufficiently  to  avoid  a  postoperative  labial 
notch.  It  is  not  necessary  to  leave  a  great  excess  of  tissue  at  the  lip 
border  in  order  to  overcome  the  effect  of  scar  contraction.  With 'clean 
work  this  is  really  a  very  inconsiderable  factor.  A  small  amount  of 
superabundant  tissue  should  be  removed,  but  this  will  be  very  little 
if  the  lines  of  the  incisions  have  been  slanted  in  such  manner  as  to 
bring  most  of  the  excess  tissue  on  the  inside  of  the  lip,  where  it  is  by 
all  means  desirable  that  it  should  be  to  preserve  the  outward  roll  of  a 
symmetrical  lip  when  finished. 

Sutures. — The  first  suture  is  of  catgut  with  a  needle  at  each  end 
passed  from  the  exposed  raw  surface  on  each  inward  through  the 
mucous  membrane  sufficiently  away  from  the  wound  border  to  give 
good  tension  resistance  and  tied  on  the  inside  of  the  lip.  Other  gut 
sutures  may  then  be  passed  with  a  single  needle  from  the  under  side 
of  the  lip,  since  the  incised  tissue  surfaces  are  now  in  contact.    On  the 


HARELIP 


587 


skin  surface  horse-hair  sutures  are  carried  tlirough  the  skin  and  mus- 
cular tissue  and  out  in  a  similar  manner  to  the  other  side  of  the  lip. 
This  suture  controls  hemorrhage  from  the  vessels  in  that  portion  of 
the  lip  and  enables  the  parts  to  be  brought  together  for  proper  esti- 
mation in  adjustment  of  the  surfaces.  A  similar  suture  is  placed  in 
the  same  manner  just  above  the  coronary  arteries  near  the  prolabiai 
border.  A  horse-hair  suture  or  a  2000-fine  vasehnized  linen,  as  may 
seem  best,  is  then  placed  exactly  at  the  border  of  the  skin  and 
prolabiimi.  Perfect  approximation  at  this  point  is  essential.  A 
2000  fine  linen  suture  is  inserted  at  the  opening  of  the  naris.  If 
necessary-  the  floor  of  the  nose  is  raised  by  freeing  the  skin  up  each 


Fig.  344. — Shows  diagonal  line  of  approximation.     Skin  sutures  in  place. 


side  of  the  fissure  and  held  in  position  by  fine  sutures  extending 
■^-ell  up  T^-ithm  the  naris.  In  doing  this  care  should  be  exercised  not 
to  make  the  naris  too  smaU  and  not  to  obliterate  the  angle  of  the 
curve  from  the  lip  to  the  nose  at  the  opening  of  the  naris.  The  mucous 
membrane  of  the  prolabium  is  carefully  approximated  and  held  vrith 
horse-hair  sutures  and  coaptation  sutures  of  extremely  fine  vaselinized 
linen  are  then  inserted  on  the  skin  surface.  For  this  purpose  it  is  advis- 
able to  use  fine  needles  designed  for  suturing  arteries,  or  as  the  author 
has  found  it  convenient  to  do,  the  finest  cambric  needles  that  are  made 
and  a  2000-fine  linen  tliread  ^vhicli  is  made  to  fit  the  extremely  small 
eyes  of  these  needles.  These  are  inserted  and  the  skin  approximation 
completed  by  the  aid  of  a  magnif^'ing  glass. 


588 


SURGERY  OF  THE  MOUTH  AND  FACE 


Postoperative  Control  of  Dressing. — Undisturbed  healing  and  free- 
dom from  suture-scarring,  or  perhaps  complete  disaster  through  sepa- 
ration of  the  approximated  parts,  is  given  by  carrying  a  zinc  oxide 
adhesive  plaster  strap  a  little  less  in  width  than  the  length  of  the 
nose  (in  most  cases  from  one-half  to  three-fourth  of  an  inch)  from  the 
cheek  on  each  side  across  the  bridge  of  the  nose,  and  another  similar 
strap  of  approximately  the  same  width  from  the  cheeks  across  the 
chin  and  lower  lip.  These  are  adjusted  in  such  manner  as  to  make 
just  enough  tension  to  control  muscular  action  in  the  region  of  the 


Fig.  345. — The  adhesive  strip  carried  from  the  cheek  upon  one  side  across  the  bridge 
of  the  nose  to  a  corresponding  point  upon  the  opposite  side  of  the  face.  Another  adhesive 
strip  attached  upon  the  cheek  upon  one  side  just  below  the  upper  strip,  and  carried 
across  the  chin  to  a  corresponding  point  upon  the  opposite  cheek.  Both  of  these  strips 
are  drawn  just  tight  enough  to  relieve  tension  upon  the  lip  sutures,  and  the  lower  one  is 
so  adjusted  as  to  hold  the  lips  slightly  apart  to  favor  respiration  after  operation. 
(Author's  method.) 


upper  lip.  The  lower  one  is  also  arranged  so  that  the  lower  lip  is 
turned  slightly  downward,  thus  insuring  that  the  mouth  may  be  kept 
open  during  the  period  of  reaction  from  the  operation  (Fig.  345). 
These  straps  are  left  undisturbed  until  the  sutures  are  removed.  A 
piece  of  lightly  fluffed  gauze  is  laid  across  the  upper  lip  and  attached 
upon  the  cheeks  by  short  adhesive  strips.  This  can  be  changed  by 
the  nurse  without  difficulty  whenever  it  becomes  soiled  and  the  wound 
surface  is  thus  easily  accessible  for  observation  and  postoperative 
treatment  if  necessarv. 


HARELIP 


589 


Belief  of  Tension. — ^When  the  fissure  is  unusually  wide  and  the  car- 
tilaginous wing  of  the  nose  extremely  flat  and  spread  out  there  is 


Fig.  346. — Infant  with  very  wide  fissure  through 
lip  and  hard  and  soft  palates,  also  marked  nasal 
deformity. 


Fig.  347. — Same  child  as 
shown  in  Fig.  346  at  four 
years  of  age,  after  the  lip 
and  palate  operations  have 
been  completed.  The  final 
operation  was  performed 
when  she  was  two  years  old. 
Tendency  toward  correct 
development  may  be  noted. 


Fig.  348. — -Infant  with  harehp  and 
complete  cleft  palate.  The  nose  has  been 
partially  straightened  and  the  fissures 
made  narrower  by  wearing  an  adhesive 
strip  as  described. 


Fig.  349. — Same  child  at  six  years  of 
age.  The  lip  was  closed  at  about  two 
months,  the  hard  palate  between  five  and 
six  months,  and  the  soft  palate  at  two 
and  a  half  years.  The  symmetrical  de- 
velopment of  face,  nose,  mouth  and  jaws 
at  six  years  old  seems  tc  prove  that  this 
would  not  have  been  possible  had  any 
growing  structures  been  seriously  dam- 
aged in  the  course  of  the  early  operations. 


590  SURGERY  OF  THE  MOUTH  AND  FACE 

always  marked  deflection  of  the  nasal  septum  as  well  as  the  triangular 
cartilage.  In  such  cases  the  lip  should  be  set  free  by  incisions  through 
the  gingivolabial  fold  of  the  mucous  membrane  carried  close  to  the 
bone  and  high  enough  up  to  completely  free  the  ala  on  the  affected 
side,  and  also  to  release  the  most  active  fibers  of  the  antagonizing 
muscles.  On  the  opposite  side  the  lip  attachments  to  the  premaxilla 
should  be  set  free  in  the  same  manner,  and  in  extreme  cases  the  knife 
carried  backward  to  sever  the  anterior  end  of  the  nasal  septum  close 
to  its  maxillary  attachment.  The  fixation  of  the  silkworm-gut  splint 
suture  which  has  previously  been  placed  may  then  be  depended  upon 
to  bring  about  the  necessary  readjustment  of  these  parts. 

Double  Harelip. — The  general  characteristics  of  these  cases  are  much 
the  same  as  in  single  harelip  and  yet  there  are  important  individual 
differences  as  represented  by  the  extent  of  the  deformity.  In  some 
instances  the  detached  premaxilla  is  comparatively  large  and  the 
elongation  of  the  nasal  septum  and  vomer  not  so  great  as  to  cause 
extensive  protrusion  of  the  premaxillary  structures.  This  permits  the 
overlying  lip  tissue  in  the  region  of  the  philtrum  to  be  sufficiently 
free  and  well  nourished  to  make  closure  of  the  fissure  much  more 
simple  than  in  other  cases  with  marked  protrusion  of  the  premaxilla, 
extensive  deformity  of  the  septal  structures,  and  so  little  tissue  form- 
ing the  philtrum  of  the  lip  as  to  make  any  attempt  to  make  the  neces- 
sary reconstruction  a  matter  of  great  difficulty.  In  dealing  with  this 
exaggerated  form  of  double  harelip  cases  there  is  always  a  strong 
temptation  to  adopt  the  old  type  of  operation  in  which  the  lip  fissures 
are  closed  by  freshening  the  borders  of  this  central  portion  of  the  lip 
so  as  to  make  it  form  a  three-sided  square  and  then  to  carry  across 
from  the  lip  tissue  on  each,  outside  of  the  fissure  flaps  to  be  brought 
together  and  attached  to  the  squared  edge  of  the  philtrum,  in  such 
manner  as  to  make  an  artificial  prolabium  (Fig.  350),  but  no  matter 
how  this  may  be  done  the  result  as  shown  in  Figs.  365,  367,  and  380 
is  inevitable. 

Contraction  of  the  transverse  scar  tissue  thus  formed  at  the  pro- 
. labial  border  is  invariably  such  as  to  draw  it  inward  and  downward. 
The  lip  thus  becomes  unusually  long  and  in  some  cases  almost  hope- 
lessly deformed.  It  requires  infinite  patience  and  some  courage  to 
take  the  position  that  it  is  better  to  treat  this  single  segment  of  lip 
tissue,  no  matter  how  small  it  may  be,  in  the  same  way  that  one 
would  treat  a  larger  one.  Even  though  the  immediate  effect  may  not 
be  encouraging,  once  the  lip  muscles  on  each  side  are  attached  to  the 
central  division  the  physiological  activity  will  tend  to  bring  the  parts 
into  their  normal  relation  and  cause  groAAlh  of  the  deficient  lip  tissue. 
In  the  course  of  time  this  may  be  depended  upon  to  grow  into  a  lip 
surface  of  sufficient  size  to  permit  its  later  readjustment  in  such 
manner  as  to  give  nasal,  facial,  and  labial  perfection  that  could  not 
be  secured  in  any  other  way  (Figs.  346  to  349). 

Treatment  of  the  Nasal  Septum  and  Vomer. — Inasmuch  as  there  is 
not  only  distortion  of  these  structures  but  a  superabundant  growth  as 


HARELIP 


591 


well,  these  conditions  must  be  considered  in  overcoming  the  deformity. 
No  tissue  should  be  wasted  by  excision  that  can  possibly  be  saved. 
The  removal  of  a  V-shaped  section  from  the  lower  border  of  the 
nasal  septmn  as  is  sometimes  advocated,  gives  the  mouth  a  rabbit- 
shaped  appearance  that  becomes  very  unsightly  as  the  patient  grows 
older.  In  newly  born  children  the  author  has  found  it  advisable  to 
take  advantage  of  the  double  development  of  the  nasal  septum,  the 
divisions  of  which  may  easily  be  separated  by  passing  a  strong,  broad 
knife  in  an  anteroposterior  direction  between  them.  This  makes  it 
possible  to  spread  them  apart  as  the  premaxilla  is  pressed  back  into 
position  and  not  only  prevents  loss  of  tissue  but  helps  to  reduce  the 
size  of  the  opening  in  the  palate  as  the  intervening  space  fills  in.    In 


Fig.  350. — Illustration  of  method  of  performing  double  harelip  operation  which  has 
been  -widely  emploj'ed  by  surgeons  but  which  in  the  author's  experience  invariably 
leads  to  deformities  such  as  shown  in  Figs.  365  and  367.  It  should  be  avoided  by 
everj^  possible  expedient. 


older  children  when  bone  has  formed  it  sometimes  becomes  necessary 
to  make  a  diagonal  cut  through  the  septal  structures  to  allow  them  to 
slide  past  each  other  when  the  premaxilla  is  brought  into  position. 
The  supporting  splint  tension  suture  is  passed  from  the  skin  surface 
just  outside  of  the  angle  of  the  cartilaginous  wings  of  the  nose  on  each 
side  thiough  the  nasal  septum  so  that  when  the  silver  plates  and  shot 
are  adjusted  the  parts  are  held  in  proper  relation  (Fig.  350). 

Each  lip  fissure  is  closed  separately  as  by  two  simultaneous  single 
harelip  operations  (Figs.  351  and  352).  In  some  cases  the  premaxilla  is 
almost  entirely  absent  and  there  is  practically  no  lip  tissue  in  the  region 
of  the  philtrum.  Under  such  circumstances  it  may  be  absolutely 
necessary  to  extend  tissue  from  the  outside  lip  borders  across  to  the 
central  line  but  such  conditions  are  very  rare.    With  care  to  avoid 


592 


SURGERY  OF  THE  MOUTH  AND  FACE 


traumatic  injury  and  by  not  making  the  sutures  tight  enough  to  cut 
off  the  circulation,  the  necessary  two  rows  of  sutures  may  be  success- 


Fi(i.  351. — Author's  method  of  double  harelip  operation.    Fissure  borders  prepared  for 
the  sutures.     First  control  suture  in  place. 


Fig.  352. — Author's  method  of  double  harelip  operation, 
and  skin  suture  in  place. 


The  operation  completed 


HARELIP 


593 


fully  passed  through  quite  small  portions  of  the  lip  philtrum  and 
good  immediate  results  can  be  accomplished  with  the  assurance  that 


Fig.  353.- 


-Child  with  double  harelip  and  a  cleft  palate  that  has  previously  been  operated 
without  success. 


future  development  will  bring  a  continued  improvement  in  cosmetic 
effect.    Figs.  353  to  372  show  the  results  of  such  treatment. 

After-treatment. — The  less  the  wound  is  disturbed  in  the  course  of 
after-treatment  the  better.  Because  of  the  likelihood  of  infection  from 
the  nose  and  mouth  it  is  not  advisable  to  use  a  dressing  which  will 


Fig.  354. — Same  child  as  shown  in  Fig.  353,  after  the  lip  has  been  corrected.  This 
illustrates  in  slight  degree  the  difficulty  of  overcoming  the  appearance  of  flatness  of 
the  anterior  part  of  the  mouth  when  the  underlying  bone  structures  have  been  com- 
pressed in  an  attempt  to  close  the  palate  fissure. 

prevent  its  constant  observation.    If  interference  appears  to  be  neces- 
sary, touching  with  applicators  dipped  in  dioxogen  serves  to  give  the 

VOL.  I — 38 


594 


SURGERY  OF  THE  MOUTH  AXD  FACE 


necessary  cleanliness  after  which  alcohol  applied  in  the  same  manner 
dries  and  cleanses  without  disadvantage. 

The  Correction  of  Postoperative  Lip  and  Other  Associated  Xasal  Defects. 
— There  is  almost  no  limit  to  the  possibilities  of  improvement  that 
may  be  made  by  the  correction  of  the  lips  and  noses  of  the  unfortunate 


Fig.  355. — Infant  with  double  harelip. 


Fig.  356. — Same  child  after  operation. 


victims  of  early  operation.  Bearing  in  mind  the  fact  that  these 
defects  are  chiefly  due  to  three  causes  corrective  efforts  must  be  directed 
in  such  manner  as  to  overcome  them  to  the  best  advantage. 

The  first  type  of  these  cases  is  represented  by  the  individuals  whose 
features  have  become  distorted  through  the  destruction  of  some 
essential  developmental  structure. 


Fig.    357.  —  Characteristic    scar    with 
notch  following  harelip  operation. 


Fig.  358. — .Same  young  man  as  shown 
in  Fig  357  after  correction  of  the  lip  defect 
and  closure  of  a  wide  fissure  through  both 
hard  and  soft  palates. 


The  second  by  those  who  have  suffered  increase  or  at  least  continua- 
tion of  the  original  nasal  and  facial  distortion  through  failure  to 
bring  properly  into  play  the  corrective  influences  that  would  iiave  been 
exerted  if  there  had  been  proper  readjustment  of  these  features  in 


HARELIP 


595 


infancy.       In  both  these  types  there  will  be  usually  found  much 
unsightly  scar  tissue  (Fig.  392). 


Fig.  359. — -Child,  aged  two  and  one- 
half  years.  One-half  of  lip  and  palate 
almost  totally  destroyed  as  a  result  of 
attempted  closure  of  lip  and  palate  at 
the  same  time.  Forcible  compression  of 
the  sides  of  the  palate  was  attempted  in 
early  infancy. 


Fig.  .360. — The  result  of  closure  of  the  lip 
for  the  little  girl  shown  in  Fig.  359. 


Fig.  361  Fig.  362 

Fig.  361. — Front  ^^ew  of  boy,  aged  four  years,  for  whom  the  operation  of  forcibly 
closing  his  palate  fissure  and  attempting  to  hold  the  parts  with  wire  and  lead  plates 
was  performed  in  early  infancy.  The  lip  was  closed  at  the  same  operation.  Both  lip 
and  palate  sloughed  out  except  for  a  small  bridge  of  tissue  which  fixed  the  maxillary 
bones  as  placed.  Not  only  did  he  lose  almost  the  entire  lip  upon  one  side,  but  the 
deformed  shape  of  his  face,  which  is  characteristic  of  the  result  of  these  operations, 
remains  permanently,  as  is  plainly  shown  in  the  illustration. 

Fig.  362. — Same  boy  as  shown  in  Fig.  361,  several  years  after  operation. 

The  third  form  of  postoperative  deformity  in  these  cases  is  due  to 
an  increase  in  size  as  well  as  deformity  of  the  immediately  associated 


596 


SURGERY  OF  THE  MOUTH  AND  FACE 


parts.    This  is  usually  noticeable  in  the  cartilages  at  the  end  of  the  nose,| 
more  especially  the  cartilago  alaris  major  and  the  lateral  nasal  car- 


FiG.  363. — Child,  aged  three  years.  Lip 
nearly  half  lost  by  operation  upon  both 
lip  and  palate  at  the  same  time  in  early 
infancy. 


Fig.  364. — Same  child  as  shown  in  Fig. 
363  after  closure  of  the  lip  fissure.  Brown's 
O.  D.  and  M. 


Fig.  365. — Front  view  of  boy  whose 
palate  was  closed  in  early  infancy  with 
what  appeared  to  be  a  successful  opera- 
tion. The  result  at  seven  years  old  may 
be  seen.  Complete  stenosis  of  left  naris, 
right  side  of  nose  almost  absolutely  useless 
for  breathing  purposes,  although  probe 
can  be  passed  through.  Disproportion 
between  the  upper  and  lower  parts  of  the 
face  and  head  due  to  arrest  of  develop- 
ment. Voice  shrill,  high,  and  by  no 
means  perfect  in  pronunciation. 


Fig.  366. — Front  view  of  same  boy  as 
shown  in  Fig.  365  after  operation  for 
the  correction  of  his  lip  and  facial  de- 
fects. 


HARELIP 


597 


tilage.     The  operation  for  correction  of  this  defects  is  sho\Mi  in  Figs. 
373  and  374. 


Fig.  367. — A  young  man  whose  lip  was 
operated  upon  in  early  infancy  -without 
due  consideration  for  developmental  prin- 
ciples. 


Fig.  368. — The  same  indi\"idual  shown 
in  Fig.  367  after  operation  upon  the  lip 
and  readjustment  of  the  deformed  parts. 


Direction  of  the  Line  of  Scar. — A  diagonal  line  of  approximation 
not  only  gives  the  advantage  of  a  slanting  scar  but  also  tends  to  pre- 
vent the  intensification  of  the  defect  when  the  lip  is  under  tension  as 


Fig.  369. — Boy,  aged  fourteen  years, 
with  harelip  and  cleft  palate.  Shows  the 
increase  of  the  deformity  that  occurs 
when  such  cases  are  neglected  until 
advanced  stage. 


Fig.  370. — The  same  boy  as  in  Fig. 
369  after  both  lip  and  palate  have  been 
closed. 


in  smiling.    Not  infrequently  a  lip  that  looks  well  when  the  parts  are 
at  rest  will  show  a  very  unsightly  scar  when  the  individual  laughs. 


598 


SURGERY  OF  THE  MOUTH  AND  FACE 


In  boys  a  mark  well  to  one  side  of  the  central  line  can  readily  be 
covered  by  a  mustache  which  would  show  a  noticeable  defect  if  part- 


FiG.  371. — Infant  with  double  harelip 
and  cleft  palate.  The  history  of  this  case 
before  coming  to  me  shows  that  a  few  daj-s 
after  birth  an  attempt  was  made  to  close 
the  palate  fissure  by  the  use  of  silver  wire 
and  lead  plates.  The  wires  sloughed  out 
and  there  was  a  general  infection,  as  a  re- 
sult of  which  the  child  was  in  a  very  criti- 
cal state  for  several  weeks  before  recovery. 


Fig.  872.  —  The  same  baby  after  I 
have  closed  the  lip  and  hard  palates.  It 
will  be  seen  that  it  was  impossible  to  get 
as  perfect  a  result  as  might  have  been 
obtained  had  the  first  operation  not  been 
performed. 


Fig.  373. — Shows  the  method  of  removing  the  excessive  tissue  from  the  cartilaginous  end 
of  the  nose  in  such  cases  without  external  incisions,  thus  avoiding  scar  disfigurement. 


ing  in  the  central  line  were  interfered  with  as  would  be  the  case  if 
the  scar  were  close  to  the  situation. 

In  girls,  effort  should  be  made  to  bring  this  line  as  close  to  the 


HARELIP 


599 


median  line  of  the  lip  as  may  be  practicable  because  the  usual  depres- 
sion tlu-ough  the  central  portion  of  the  philtrimi  or  the  columns  of  the 


Fig.  374 — Fixation  suture  in  place  for  operation  illustrated  in  Fig.  373. 


Fig.  375. — A  man,  aged  twenty-five  years,  who  had  had  many  previous  operations  for 

harelip  and  cleft  palate. 


lip  on  each  side  of  this  central  depression  may  be  simulated  to  such 
an  extent  as  to  almost  completely  hide  the  original  trouble.  The 
same  rules  should  be  kept  in  mind  in  the  adjustment  of  the  lines  of 


GOO 


SURGERY  OF  THE  MOUTH  AND  FACE 


approximation    in   double   harelip   operations,   without    endangering 
the  immediate  result  too  much  by  efforts  in  this  direction. 


Fig.  376. — Same  young  man  after  excision  of  scar,  readjustment  of  prolabial  border, 
correction  of  the  form  of  the  alar  cartilages  and  the  removal  of  the  flatness  on  right 
side  of  cartilaginous  tip  of  nose  by  the  insertion  of  a  rib  cartilage  transplant  through 
an  incision  made  just  inside  the  skin  border  at  the  outer  anterior  part  of  the  nans. 
Restoration  of  the  outlines  may  be  noted. 


CLEFT  PALATE. 

The  types  of  cleft  palate  in  form  and  character  from  a  bifid  uvula 
with  both  hard  and  soft  palates  otherwise  intact,  to  fissures  which 
divide  the  velum  palati  or  the  bony  palate  partially  or  completely, 
and  continue  entirely  through  the  alveolar  ridge  and  the  lip.  Such 
clefts  may  be  confined  to  either  of  the  two  palatal  divisions  without 
the  other  being  affected,  and  they  may  be  single  or,  if  associated  with 
double  harelip,  be  divided  through  the  central  line  bj'  the  nasal  septum 
and  the  vomer  in  such  manner  as  to  have  the  appearance  of  a  double 
cleft  palate. 

The  Non-surgical  Treatment  of  Palatal  Fissures. — The  non-surgical 
treatment  of  palatal  fissures  by  the  use  of  obturators  in  the  form  of 
plates  with  artificial  vela  capable  of  more  or  less  movement  in  speech 
is  usually  unsatisfactory.  Such  appliances  have  sometimes  been 
brought  to  a  very  high  degree  of  perfection  and  there  have  been  notable 
examples  of  individuals  who  have  acquired  almost  perfect  speech 
through  the  assistance  of  these  mechanical  aids.  Nevertheless  a  palate 
fissure  closed  by  natural  tissue  with  the  muscles  properly  approximated 


CLEFT  PALATE  601 

is  in  all  respects  more  advantageous.  This  is  not  only  true  with  regard 
to  speech,  but  also  because  tissue  restoration  favors  conditions  which 
pertain  to  improved  local  as  well  as  general  health  and  cleanliness. 
A  palate  surgically  restored  gives  a  feeling  of  satisfaction  to  the  affected 
individual  that  an  artificial  substitute  never  can  approximate. 

The  Standard  of  Staphylorrhaphy. — The  following  principles  should 
govern  the  selection  of  a  method  for  the  surgical  treatment  of  cleft 
palate.^ 

1 .  A  deformity  should  not  be  corrected  by  surgical  or  other  forcible 
means  if  such  defect  may  be  made  to  correct  itself  in  the  natural  course 
of  development,  or  if  its  presence  does  not  interfere  with  perfect 
function  of  the  palate. 

2.  No  structure  should  be  destroyed  that  may  be  required  for  the 
perfection  of  future  developmental  processes. 

3.  No  tissue  should  ever  be  misplaced  or  otherwise  altered  in  such 
manner  as  to  impair  its  future  functional  usefulness. 

4.  The  reparative  possibilities  of  tissue  in  flap  formation  should  not 
be  overtaxed  in  an  endeavor  to  close  completely  at  one  operation  the 
palate  fissure  of  cases  in  which  this  is  inadvisable. 

The  several  distinct  operative  methods  in  performing  staphylorrhaphy 
are: 

1.  Compression  (forcing  the  sides  of  the  bony  palate  in  early  infancy 
as  advocated  by  Garretson,  Brophy  and  others);  (2)  flap-reversing 
operations  (Lane,  Davies-Colley) ;  (3)  bone  and  mucoperiosteum  flap 
formation  (Ferguson).  (4)  Median  mucoperiosteal  Hap-sliding  opera- 
tions (von  Langenbeck- Warren). 

Compression  Method. — The  most  widely  known  operation  of  this 
type  as  perfected  by  Dr.  T.  W.  Brophy  of  Chicago,  is  performed  in 
early  infancy  and  before  the  lip  fissure  is  closed.  Silk  ligatures  in 
special  needles  are  carried  through  the  upper  jaw  above  the  bony 
palate  on  each  side.  By  the  aid  of  the  loops  thus  formed,  silver  wire, 
18  to  20  (American  gauge),  is  carried  completely  through  at  both  the 
anterior  and  posterior  portions  of  the  mouth.  These  wires  are  threaded 
through  holes  in  lead  plates  of  suitable  size  and  shape  in  such  manner 
as  to  cause  compression  when  the  wires  are  twisted  and  the  maxillse 
forced  together  to  close  the  anterior  portion  of  the  cleft,  the  borders 
of  which  are  duly  freshened  and  the  posterior  portion  of  the  palate 
closed  with  sutures  (Fig.  366)  .^  High  mortality  is  a  serious  objection 
to  this  operation.  While  it  is  true  that  newly  born  infants  withstand 
the  shock  of  operation  in  some  respects  better  than  older  children,  they 
are  nevertheless  highly  susceptible  to  the  effect  of  continued  irritation, 
infection  and  diflBculties  in  taking  nourishment.  These  disadvantages 
are  necessarily  attendant  upon  the  retention  of  wires,  lead  plates  and 
similar  substances  in  the  jaws,  nose  and  mouth.  There  is  good  reason 
to  believe  that  if  the  death-rate  under  this  method  as  employed  by 
surgeons  during  past  years  could  be  shown  it  would  be  appalling.    It 

*  Lancet,  September  12,  1914.     Surg.,  Gynec.  and  Obst.,  vol.  xx,  No.  1. 
"^  Berry  and  Legg :  Harelip  and  Cleft  Palate. 


602 


SURGERY  OF  THE  MOUTH  AND  FACE 


also  eiuiaiigers  the  developmental  i)ro('esses  upon  which  the  future 
form  of  the  nares,  the  palate,  the  upper  dental  arch  and  the  face 
depend.  Compression  of  this  character  cannot  fail  to  cause  an  unneces- 
sary degree  of  deflection  of  the  nasal  septum  and  marked  narrowing 


Fig.  377. — Boy,  aged  nine  years.  An  attempt  was  made  to  close  the  palate  fissure 
by  compression  in  early  infancy.  This  failed,  and  many  subsequent  palate  operations 
also  failed  as  a  result  of  the  first  one.  I  have  recently  closed  the  remaining  palate  opening, 
but  the  deformity  will  be  difficult  to  overcome. 


Fig.  378. —  Girl,  aged  six  years.  An 
operation  to  close  the  palate  fissuie  by 
compression  and  wiring  in  early  infancy 
failed.  Several  later  attempts  by  other 
operators  also  failed.  As  a  result  of  this 
early  treatment  the  entire  upper  palatal 
arch  is  less  than  the  size  of  a  twenty-five 
cent  piece  in  diameter,  and  all  the  teeth 
but  four  due  at  this  age  were  destroyed 
by  the  wires. 


Fig.  379. — Profile  view  of  the  same  boy 
as  in  Fig.  361.  The  malposition  of  the 
maxillaj  and  consequent  deformity  of  the 
nose  which  resulted  from  forcing  these 
bones  together  to  close  the  palate  fissure 
in  early  infancy  are  markedly  apparent. 


of  the  nares.  Wires  employed  for  retention  purposes  when  passed 
through  the  upper  maxillse  of  an  infant  inevitably  destroy  from  one  to 
four  or  more  of  the  developing  tooth  germs  therefore  these  teeth  do  not 
erupt. 


CLEFT  PALATE 


603 


The  claim  that  in  passing  a  needle  through  the  upper  maxillary  bones 
of  infants,  the  developing  teeth  may  be  avoided  by  sense  of  touch  when 
the  point  of  the  needle  meets  unerupted  teeth,  is  misleading.  This  may 
be  true  to  some  extent  in  so  far  as  the  calcified  crowns  of  the  teeth 
are  concerned,  but  the  wide  open  root  portion  of  the  partly  developed 
tooth  presents  no  such  hard  surface  to  indicate  when  the  needle  may 


Fig.  380.  —  Boy,  aged  seven  years. 
Shows  the  characteristic  facial  appearance 
after  the  removal  of  the  intermaxillary 
bone  in  operation  for  double  harelip. 


Fig.  381. — Side  view  of  boy  shown  in 
Fig.  366,  also  Fig.  380  after  operation  for 
the  restoration  of  more  natural  lines  in 
profile. 


Fig.  382. — Boy,  aged  nine  years.  Pre- 
vious history  shows  that  an  operation 
was  performed  in  early  infancy  in  which 
an  endeavor  was  made  to  close  the  palate 
by  the  use  of  wires  through  the  jaws  and 
lead  retaining  plates.  This  failed  dis- 
astrously, and  was  followed  by  four 
other  operations  with  only  partial  suc- 
cess. The  difficulties  were  enormously 
increased  by  the  effect  of  the  early  infancy 
operation. 


Fig.  383. — Same  boy  as  shown  in  Fig. 
382,  after  lip  and  nose  have  been  recon- 
structed and  the  palate  fissure  closed  by 
two  operations.  It  was  necessary  for  me 
to  readjust  the  malposed  parts  and  partly 
close  the  palate  fissure  at  the  first  opera- 
tion, and  to  complete  the  closure  one  j^ear 
later.  Since  this  picture  was  taken  he 
has  been  for  several  years  under  treat- 
ment by  his  dentist,  who  has  been  en- 
deavoring to  bring  the  malposed  teeth 
into  proper  alignment. 


be  passing  through  its  really  vital  portion  (Fig.  377) .  Without  the 
eruption  of  the  full  number  of  teeth  there  cannot  be  a  normally  shaped 
dental  arch  or  palatal  vault.  It  is  obvious,  then,  that  with  intranasal 
deformity  there  must  be  a  tendency  to  nasal  disease,  that  with  arrested 
maxillary  development  there  cannot  be  a  symmetrical  face,  and  with  a 
contracted  palatal  vault,  as  well  as  an  irregular  dental  arch,  the  best 
speech  function  is  impossible.    Figs.  377  to  383  show  the  result  of  this 


604  SURGERY  OF  THE  MOUTH  AND  FACE 

treatment  in  these  cases  and  many  similar  examples  might  be  shown  if 
necessary  to  prove  that  such  effects  are  not  uncommon. 

Clavips. — Various  forms  of  metal  clamps  for  reducing  palate  fissures 
have  been  recommended.  The  same  objections  which  pertain  to  other 
methods  of  maxillary  compression  in  cleft  palate  cases  apply  to  the 
effect  of  their  appliance  also.  Dr.  Ulrich  of  Copenhagen  has  devised 
a  clamp  which  grips  the  jaws  with  arms  that  may  be  gradually  tight- 
ened by  the  adjustment  of  nut  and  screw.  In  this  relation  it  is  sufficient 
to  say  that  the  employment  of  assistance  of  this  character  is  unneces- 
sary for  successful  palate  closure  no  matter  how  w^ide  the  fissure  may 
be.  The  author's  adjustable  fissure-narrowing  splint  attached  to  the 
teeth  on  each  side,  and  tightened  with  a  screw,  may  be  useful  in  very 
wide  fissure  cases.  Cutting  and  partially  fracturing  the  maxillary 
bones  on  each  side  prevents  narrowing  the  nares  when  pressure  is 
applied.    Such  assistance  is  very  seldom  if  ever  necessary. 

Transplantation  of  Tissue  to  Cover  Palate  Openings. — Of  passing 
interest  but  no  practical  value,  except  in  cases  in  which  previous  opera- 
tions have  destroyed  a  great  portion  of  the  original  tissues,  are  the 
reports  of  attempts  to  carry  flaps  from  the  lips,  cheeks,  chin  and  other 
extrapalatal  surfaces  and  attach  them  in  the  mouth  to  cover  palatal 
fissures.  Fixation  of  a  finger  in  the  palate  and  other  experiments  of 
like  nature  have  also  been  reported. 

Reversal  of  Mncoperiosteiim  in  Flap  Formation.  —  In  the  Lane 
operation  an  incision  is  made  along  the  alveolar  ridge  on  one  side  of 
the  mouth  in  infant  cases,  or  close  to  the  gingival  borders  of  the  teeth 
on  one  side  for  older  patients.  The  mucoperiosteum  on  that  side 
of  the  palate  is  separated  from  the  bone  surface  in  such  manner  as  to 
leave  its  attachment  along  the  border  of  the  fissure  unimpaired, 
thus  forming  a  flap  which  can  be  turned  over  and  secured  underneath 
the  periosteum  on  the  opposite  side  when  freed  by  making  an  incision 
along  the  inner  border  of  the  fissure  (Figs.  384  and  385) .  When  the  parts 
are  sutured  in  this  position  the  mucous  membrane  of  the  reversed  flap 
is  toward  the  nose  and  its  raw  periosteum  on  the  oral  surface.  Sir 
Arbuthnot  Lane  of  London,  performs  this  operation  on  infants  in  a 
wonderfully  skilful  manner.  There  is  practically  no  tension  and  the 
approximation  of  the  thick  raw 'surfaces  thus  secured  by  the  use  of  his 
special  needle-holder  and  very  fine  needles  would  be  very  advantageous 
were  it  not  for  certain  definite  reasons  which  appear  to  make  every 
such  operation  inadvisable. 

Assuming  that  complete  union  may  have  taken  place  and  the  raw 
exposed  surface  of  the  reversed  flap  completely  healed  the  transposition 
of  tissue  in  this  manner  must  militate  against  perfection  of  form  at  the 
posterior  portion  of  the  soft  palate.  This  bears  an  important  relation 
to  speech  function.  It  is  also  safe  to  assume  that  whether  bone  might 
or  might  not  form  from  periosteum  that  is  kept  in  its  normal  situation, 
as  in  other  operations,  it  certainly  cannot  do  so  with  osteogenetic 
activities  destroyed  by  this  transposition. 

The  author  has  seen  large  numbers  of  persons  who  had  no  visible 


CLEFT  PALATE 


605 


palate  fissures  and  yet  who  had  all  the  characteristic  cleft  palate  defects 
because  the  palate  bone  formation  was  imperfect.  It  is  therefore  not 
suflScient  for  speech  purposes  to  secure  a  mere  covering  of  soft  tissue 
across  palate  fissures  for  both  form  and  underlying  support  are 
important  factors.  Murray,  Berry  and  others  criticise  the  Lane  opera- 
tion by  calling  attention  to  the  fact  that  there  do  not  appear  to  be  many 
examples  of  patients  who  were  operated  upon  in  infancy  according  to 
Lane's  method  who  have  acquired  good  speech  in  later  life.  Another 
serious  objection  is  that  if  sloughing  were  to  take  place  with  the  palate 
tissue  treated  in  this  manner  the  loss  would  necessarily  be  such  as  to 
injure  it  almost  beyond  repair. 


Fig.  384. — Lane's  method  of  removing 
mucoperiosteal  flap  from  hard  and  soft 
palate  upon  one  side  of  the  cleft,  and 
tucking  the  edge  of  this  flap  under  the 
mucosa  through  a  slit  upon  the  opposite 
side  of  the  cleft.     (After  Eastman.) 


Fig.  385. — Edge  of  flap  tucked  under 
slip  upon  opposite  side  of  cleft  and 
sutured.      (After  Eastman.) 


The  Davies-Colley  Operation. — Follows  the  same  idea  as  that  of  Lane. 
According  to  this  method  a  mucop#iosteal  flap  upon  one  side  is 
reversed,  a  flap  that  is  free  at  the  anterior  end  with  a  broad  pedicle  at 
the  posterior  portion  of  the  palate  is  carried  over  and  laid  on  top  of  the 
raw  surface  of  the  reversed  flap  (Fig.  386).  This  method  also  tends  to 
relieve  tension  and  does  give  a  certain  proportion  of  the  thick  raw 
surface  which  favors  healing,  but  it  is  open  to  the  same  objections 
previously  outlined  in  connection  with  the  Lane  Operation.  Finally 
it  may  be  said  that  none  of  these  methods  are  necessary  because  good 
results  can  be  obtained  by  operations  which  do  not  entail  these  objec- 
tionable features. 

Method  of  Including  Bone  with  Mucoperiosteum  in  Flap  Formation. — 
This  operation  which  was  devised  by  Ferguson,  advocated  and  prac- 
ticed for  years  by  Dr.  J.  Ewing  Mears  of  Philadelphia,  and  then 


606 


SURGERY  OF  THE  MOUTH  AND  FACE 


allowed  to  become  almost  obsolete,  has  comparatively  recently  been 
improved  by  Koe  of  Philadelphia  with  very  good  results.  Incisions  are 
made  along  the  borders  of  the  teeth  on  each  side  down  to  the  bone 
surfaces.    With  a  chisel  the  bone  structures  on  each  side  of  the  palate 


,-<ffl> 


Fig.  386. — Davies-CoUcy  operation  for  cleft  of  the  hard   palate.     Flaps  in   position. 

(After  Treves.) 

are  cut  through  in  a  slanting  direction  toward  the  central  line.  "E" 
banjo  wire  strings  used  for  sutures  are  passed  into  holes  made  through 
the  bone  on  each  side  of  the  fissure.  The  anterior  bony  attachments 
are  freed  by  forcing  the  parts  together  from  each  side,  and  the  wire 
sutures  are  tied  in  such  manner  as  to  make  a  complete  approximation 
in  the  central  line.    The  soft  palate  is  then  closed  (Fig.  387).     The 


Fig.  387. — Fissures  of  the  hard  palate:  A,  preliminary  punctures  with  awl  to  give  line 
for  chisel;  B,  incision  through  bone  completed  by  chisel;  C,  holes  bored  through  hard 
and  soft  palates  for  sutures;  D,  junction  of  hard  and  soft  palate;  E,  lateral  openings 
subsequently  filled  up  by  granulation.     (Bryant.) 

promise  of  securing  actual  bone  formation  in  symmetrical  outline  at  the 
posterior  portion  of  the  hard  palate  that  this  method  gives  is  one  that 
merits  its  due  consideration.  Roe  seems  to  hnxe  had  little  difficult.y 
with  necrosis  of  the  bone  included  in  the  flaps  but  it  must  be  kept  in 


CLEFT  PALATE  607 

mind  that  if  such  necrosis  did  occur  through  extensive  sloughing  there 
would  be  danger  of  completely  ruining  the  palate  for  future  operative 
purposes.  The  editor  has  had  many  good  results  with  his  own  adapta- 
tion of  these  methods. 

Median  Flap  Sliding  Operation. — Although  Lemonier,  a  French 
dentist,  in  1764  originally  proposed  and  took  the  first  steps  toward 
surgical  closure  of  a  cleft  in  the  soft  palate,  and  in  1819  Roux,  of  Paris, 
performed  such  an  operation,  Warren,  of  Boston,  in  1820,  seems  to 
have  been  the  first  one  to  surgically  close  a  cleft  palate  with  sufficient 
success  to  warrant  continuance  of  the  method.  To  von  Langenbeck 
is  due  the  credit  of  having  suggested  and  successfully  practiced  closing 
of  fissures  of  the  hard  palate  by  making  incisions  upon  each  side,  raising 
the  mucoperiosteum  and  suturing  it  through  the  central  line  of  the 
palate.  All  of  the  urano-staphylorrhaphy  methods  of  this  t\T3e  are 
based  upon  the  principles  of  this  operation.  The  author  has  secured 
his  best  results  by  modifying  and  adapting  the  principles  of  the  von 
Langenbeck- Warren  operation  to  the  formulation  of  a  system  whereby 
one  operative  step  leads  gradually  to  the  next  from  the  very  earliest 
period  of  infancy.  All  the  necessary  operations  are  completed  before 
the  child  is  old  enough  to  talk  and  thus  the  acquirement  of  wrong 
speech  habits  is  avoided.  In  this  way  also  the  surgical  difficulties  of 
each  successive  operation  may  be  reduced  without  unnecessary  destruc- 
tion of  important  developmental  structures,  and  with  the  best  possible 
alignment  of  the  osseous  and  muscular  parts  to  the  end  that  future 
growth  and  functional  opportunities  may  be  favored. 

Operative  Steps  According  to  the  Author's  Methods. — Age  of  Operation. 
— In  the  treatment  of  infants  with  complete  fissure  through  lip  and 
palate  it  is  advisable  to  close  the  anterior  portion  of  the  cleft  including 
as  much  of  the  hard  palate  as  possible,  as  soon  as  the  child  may  have 
fully  recovered  from  the  effect  of  the  lip  operation  (Fig.  388) .  Usually 
tliis  means  at  approximately  four  to  six  months  of  age.  The  velum 
palati  is  closed  one  year  later  with  less  danger  to  the  child  and  more 
certainty  of  securing  a  perfect  result  than  if  the  entire  palate  were 
closed  throughout  at  one  operation  (Fig.  389).  By  having  the  palate 
so  completed  before  the  child  begins  to  talk  there  is  less  likelihood  of 
the  acquirement  of  WTong  speech  habits  w^hich  are  sometimes  difficult 
to"  overcome  in  later  life. 

In  cases  of  older  children  and  adults,  both  the  uranoplasty  and 
staphylorrhaphy  may  be  simultaneously  performed.  When  the  cleft 
does  not  extend  through  the  alveolar  portion  of  the  jaw  the  time  of 
operation  should  be  governed  by  the  circumstances  of  the  case  and  a 
complete  closure  of  the  cleft  effected  without  the  two-stage  method  of 
operation. 

Control  of  Hemorrhage. — With  the  raw  surfaces  of  palatal  flaps 
exposed  in  the  nasal  region  and  the  other  necessary  incisions  there  is 
much  opportunity  for  blood  oozing  if  abnormal  conditions  be  encoun- 
tered. It  is  therefore  an  advisable  precaution  to  have  the  coagula- 
bility of  the  blood  tested  in  addition  to  the  usual  preoperative  blood 
examination. 


608 


SURGERY  OF  THE  MOUTH  AND  FACE 


Fig.  388. — The  author's  method  of  palate  operation  for  infants.  The  attachments 
slipped  through  the  arm  of  the  modified  gag  clasp  the  anterior  part  of  the  alveolar  ridge 
as  shown.    The  incisions  as  used  for  these  cases  are  as  described. 


Fig.  389. — The  hard  palate  closed  and  the  tissue  of  soft  palate  brought  close  together 
but  not  sutured  as  advocated  for  infants  when  the  hard  palate  is  cleared  first,  and  the 
soft  palate  one  year  later  as  described  in  the  text. 


CLEFT  PALATE  609 

Fortunately  air  will  pass  freely  through  lightly  packed  gauze  when 
blood  will  not,  and  taking  advantage  of  this,  a  narrow  strip  of  gauze, 
folded  as  for  gauze  drainage,  is  packed  lightly  into  the  pharynx  with 
one  end  projecting  out  at  the  corner  of  the  mouth  for  safety.  This 
in  the  author's  opinion  is  a  more  suitable  method  for  palate  operations 
than  that  of  passing  a  tube  into  the  trachea  and  firmly  packing  gauze 
around  it  in  the  pharynx.  The  anesthetic  tube  is  thus  left  entirely 
in  view  and  there  is  less  danger  of  the  condensation  of  the  anesthetic 
allowing  it  to  be  blown  directly  into  the  bronchi  and  lungs.  There 
is  also  an  advantage  in  having  the  faucial  arches  left  entirely  free  from 
fixation  or  distortion  by  firmly  packed  gauze.  Every  endeavor  should 
be  made  to  avoid  the  larger  vessels  as  much  as  possible  t3  reduce 
hemorrhage  and  insure  better  flap  nourishment. 

Paring  the  Fissure  Borders. — Notwithstanding  the  following  very 
timely  suggestions  by  Berry^  who  says,  "If  the  edges  are  pared  before 
the  detachment  of  the  soft  tissues  from  the  bones,  they  are  exposed  to 
injury  and  infection  from  sponges  and  instruments  during  the  subse- 
quent stages,"  the  author  believes  that  the  counteracting  influences 
to  which  Berry  also  calls  attention  when  he  asserts  that  the  "only 
objection  to  late  paring  is  that  it  is  a  little  more  difficult  to  cut  neatly 
along  the  edge  of  a  loose  fold"  is  more  important  than  any  disadvantage 
which  may  be  suffered  through  the  impaired  freshness  of  the  exposed 
tissue  border. 

Position  of  the  Patient. — The  position  of  the  patient  is  the  same  as 
described  for  harelip  operations.  With  the  shoulders  raised  sufficiently 
to  tip  the  head  backward  all  the  advantages  of  the  Rose  position  with 
the  head  hanging  over  the  end  of  the  table  are  secured.  It  has  always 
seemed  to  the  author  that  he  could  approximate  the  palate  borders 
in  more  natural  alignment  when  he  faced  the  operative  field  directly 
than  he  could  if  viewing  it  in  reverse  position  as  is  usually  done  by 
those  who  favor  the  Rose  position.  This,  however,  is  a  matter  of 
personal  choice  and  not  of  vital  importance. 

Control  of  the  Field  of  Operation. — It  is  impossible  to  perform  suture 
and  tissue  adjustment  in  the  region  of  the  mouth  and  pharynx  with 
sufiicient  accuracy  unless  the  field  of  vision  be  clearly  in  view,  with 
the  jaws  and  tongue  held  firmly  in  suitable  position  and  hemorrhage 
as  well  as  excessive  mucous  secretions  under  control.  These  consid- 
erations must  be  kept  in  mind  in  selecting  a  mouth  gag.  The  author's 
mouth  gags  shown  in  Figs.  390  and  391  are  modifications  of  the  White- 
head gag  whereby  the  view  of  the  anterior  part  of  the  mouth  is  unob- 
structed and  steadiness  secured  by  the  curved  arms  which  are  fixed 
inside  the  teeth. 

Preparation  of  the  Field  of  Operation. — Whenever  possible  the  nose 
should  be  irrigated  with  saline  solution,  glycothymoline  or  some 
similar  preparation  for  as  long  a  period  of  time  before  operation  as 
may  be  practicable.     Even  a  few  hours  of  this  treatment  may  be 

1  Harelip  and  Cleft  Palate.      (Berry  and  Legg.)      Chapter  VII,  p.  197. 
VOL.  1—39 


GIO 


SURGERY  OF  THE  MOUTH  AND  FACE 


helpful.  Diseased  conditions  of  the  teeth  also  require  preparatory 
treatment.  The  face,  mouth,  teeth  and  gums  are  cleansed,  scrubbed 
and  treated  with  alcohol  and  iodine.  The  borders  of  the  fissure  are 
touched  with  applicators  dipped  in  adrenalin  to  facilitate  the  accurate 
paring  of  the  fissure  borders  by  temporarily  checking  hemorrhage. 


Fig.  390. — The  author's  self-retaining  fixation  forceps  attached  to  hold  the  soft  palate 
taut  to  favor  perfect  operative  work  upon  the  fissure  border  are  sometimes  advantageous, 
but  in  ordinarj'  cases  such  assistance  is  not  required.  A  mosquito  forceps  holds  the 
palate  border  sufficiently  taut  and  is  less  likely  to  damage  the  tissue.  Paring  the 
border  of  the  fissure.  The  author  believes  that  a  palate  border  pared  and  split  is 
more  dependable  for  a  secure  line  of  union  than  one  split  and  not  pared. 

By  splitting  the  border  to  increase  its  thickness  at  the  last  possible 
moment  before  the  sutures  are  inserted,  even  the  possibility  of  such 
disadvantage  is  overcome.  Some  writers  maintain  that  it  is  unneces- 
sary to  pare  the  borders  of  the  palate,  because  splitting  them  is  suffi- 
cient, and  in  this  way  a  saving  of  tissue  is  effected.  In  this  regard  it 
is  important  to  consider  that  the  differences  in  the  character  of  the 
tissue  at  the  borders  of  palate  fissures  are  often  very  great,  especially 
when  previous  operations  have  been  performed  which  were  followed 


CLEFT  PALATE 


611 


by  sloughing.  It  is  therefore  quite  certain  that  what  might  be  a  suffi- 
cient preparation  to  secure  union  in  one  case  would  be  absolutely- 
insufficient  in  another.  There  is,  moreover,  a  considerable  alteration 
in  the  line  of  tissue  approximation  during  the  contractions  which  are 
sometimes  associated  with  the  healing  of  the  parts.  For  this  reason 
it  is  absolutely  necessary  to  have  as  thick  a  border  of  raw  surface 
along  the  whole  line  of  flap  approximation  as  can  possibly  be  secured. 


Fig.  391. — Mucoperiosteum  raised  while  the  author's  knife,  safe  on  the  upper  side 
and  bent  to  a  suitable  angle,  is  used  to  sever  the  tissue  attachments  at  the  posterior 
border  of  the  hard  palate. 


It  is  also  important  that  the  line  of  approximation  may  be  perfectly 
in  accord  with  the  natural  formation  of  the  tissue  along  the  borders 
of  the  fissure.  If  tension  cannot  be  overcome  sufficiently  to  make 
the  tissue  loss  in  the  course  of  careful  border  paring  an  inconsiderable 
factor,  then  the  suture  tension  will  almost  invariably  be  too  great  in 
any  event.  The  author  believes  that  a  thin  strip  of  tissue  should  be 
carefully  removed  along  the  entire  outline  of  the  fissure  border,  par- 


612  SURGERY  OF  THE  MOUTH  AND  FACE 

ticularly  in  the  region  of  the  soft  palate  and  as  far  forward  as  it  may 
be  freely  movable.  In  the  anterior  portion  of  the  cleft  this  is  not  so 
important,  and  it  is  sometimes  unnecessary.  Every  effort  should  be 
made  to  follow  the  line  of  the  nearest  approximation  of  the  sides  of 
the  fissure  when  the  parts  are  at  rest. 

This  will  be  the  true  line  of  natural  approximation,  and  therefore 
the  one  least  likely  to  suffer  from  the  effect  of  antagonizing  muscular 
action  during  the  healing  process.  The  thickness  of  the  paring  should 
include  the  mucous  membrane  and  sufficient  underlying  tissue  to  give 
a  definite  raw  surface.  Just  before  the  sutures  are  tied,  the  freshened 
borders  are  touched  lightly  with  a  knife  to  split  them  and  allow  the 
eversion  of  tissue  to  present  a  perfectly  fresh  raw  surface.  The  thicker 
and  fresher  this  may  be  the  greater  the  certainty  of  immediate  firm 
union. 

Anesthesia. — The  author's  experience  in  operations  upon  palates 
under  local  anesthetics  and  with  analgesia  induced  by  the  adminis- 
tration of  nitrous  oxide  gas,  as  well  as  the  more  profound  states  induced 
in  the  same  manner,  has  been  such  as  to  lead  him  to  believe  thpt  the 
administration  of  ether,  when  heated,  vaporized,  and  blown  into  the 
mouth,  is  in  many  respects  the  most  desirable  anesthetic  for  these 
cases.  When  administered  by  Gwathmey's  or  some  similar  apparatus, 
this  agent  is  very  satisfactory,  and  much  safer  than  chloroform  because 
there  is  less  immediate  danger  and  much  less  likelihood  of  the  post- 
operative effects  of  chloroform  poisoning.  Although  there  may  be 
freedom  from  actual  pain  when  local  anesthesia  or  a  state  of  analgesia 
is  induced  there  is  much  to  cause  apprehension  on  the  part  of  the 
patient  as  the  operator  proceeds  and  sometimes  this  gives  rise  to 
unnecessary  shock  when  patients  are  conscious  during  the  operation. 
The  author  gives  the  usual  preliminary  hj^^odermic  injection  of 
\  gr.  morphin  and  yyo  gr.  of  atropin  about  thirty  minutes  before 
the  operation  is  begun  for  adult  patients  and  less  for  children. 

Preparation  of  Mucoperiosieal  Flaps. — A  rectangular  knife  is  car- 
ried completely  around  the  border  of  the  bony  palate  fissure,  this 
makes  it  possible  to  insert  the  mucoperiosteal  elevator  between  the 
periosteum  and  the  bone  surface.  This  incis'on  should  be  as  clean-cut 
as  possible  in  order  to  give  a  favorable  outline  when  the  flaps  are 
raised.  The  author's  periosteal  elevators  are  made  in  different  sizes 
and  with  different  angles.  This  is  advantageous,  because  the  slope 
of  the  sides  of  fissured  palates  varies  very  greatly  and  for  this  reason 
the  traumatic  injury  which  the  periosteum  may  suffer  will  be  gov- 
erned by  the  suitability  of  the  form  of  the  instrument  to  the  angle 
of  the  palate  walls.  Occasionally  the  form  of  the  palate  surfaces  may 
be  such  as  to  make  it  advisable  to  supplement  the  efforts  to  elevate 
the  mucoperiosteum  from  the  fissure  border  by  passing  a  straight 
elevator  through  an  incision  close  to  the  lingual  sides  of  the  teeth  to 
detach  the  tissue  from  above  downward.  The  fibrous  aponeurosis 
which  binds  the  velum  to  the  palate  bones,  and  also  its  nasopharyn- 
geal attachments,  are  severed  to  force  them  up  and  permit  unrestricted 


CLEFT  PALATE 


613 


coaptation  of  the  parts  and  also  to  prevent  antagonistic  muscular 
action.  For  this  purpose  the  author  has  right  and  left  knives  safe  on 
one  side  and  bent  at  an  obtuse  angle  to  facilitate  cutting  in  an  upward 
direction  at  a  favorable  angle  to  follow  the  posterior  border  of  the 
iiard  palate  without  injury  to  the  underlying  tissues.  Curved  scissors, 
as  recommended  by  Berry,  may  be  used  for  the  same  purpose  (Fig.  392) 


Fig.  392. — Silkworm  gut  tension  suture  in  place  -n-ith  silver  plate  slipped  over  its  free 
end  down  to  the  palate  surface  and  followed  by  four  lead  shot.  Method  of  freeing  the 
soft  palate  tissue,  and  forcing  it  toward  the  center  through  the  lateral  incisions.  Pad 
inserted  as  used  to  control  hemorrhage  when  necessary.  A  gauze  drain  may  also  be 
used  to  pack  this  opening. 


iS-w^wre^.— Silk,  linen,  silkworm  gut,  horse-hair  and  steel,  silver  and 
aluminum-bronze  wires  have  all  been  tried  with  more  or  less  advan- 
tage and  disadvantage.  The  objections  to  any  suture  material  which 
through  absorption  of  the  oral  secretions  may  itself  become  a  source 
of  infection  are  important.  Wire  sutures  are  difficult  to  adjust  with 
nice  approximation.  Even  though  very  carefully  inserted  they  are 
likely  to  traumatize,  and  cut  the  palate  tissues. 


61-1 


SURGERY  OF  THE  MOUTH  AND  FACE 


The  author  uses  formaHzed  pyotanin  catgut,  supplemented,  as  occa- 
sion may  require,  by  horse-hair  sutures  inserted  with  a  very  fine  needle 
after  the  palate  has  been  closed  to  give  more  perfect  coaptation  of  the 
mucous  membrane  at  points  where  retraction  seems  to  make  this 
additional  safeguard  necessary.  For  many  years  he  used  a  small 
aluminum  bronze-wire  tension  suture  inserted  through  the  muscles 
of  the  soft  palate,  supplemented  by  silver  plates  at  each  end  secured 


Fig.  393.^Fissure  borders  coapted  w-ith  pyoktanin  gut  sutures.  Wire  tension  sutures 
in  place  and  the  last  shot  being  compressed  to  hold  the  plates.  The  author  seldom  finds 
it  necessary  to  use  more  than  one  wire  retention  suture.  Occasionally  the  second  one  is 
required. 

by  lead  shot  clamped  upon  the  wire.  This  relieved  the  immediate 
strain  on  the  coaptation  sutures  and  later  gave  resistance  to  the  perni- 
cious activity  of  reunited  muscular  attachments.  Recently,  however, 
he  has  used  with  much  success  the  simpler  plan  of  substituting  silk 
worm  gut  for  the  wire.  It  serves  the  same  purpose,  its  insertion  requires 
less  skill  in  avoidance  of  traumatic  injury,  and  if  through  accident  it 
should  become  detached  and  swallowed,  a  silk  worm  suture  would  be 
less  troublesome  than  wire  (Fig.  393). 


CLEFT  PALATE  615 

This  suture  is  placed  first  and  tightened  just  enough  to  hold  the 
parts  of  the  soft  palate  sufficiently  close  together  to  facilitate  placing 
the  other  sutures  without  undue  tissue  strain  or  the  traumatism 
which  sometimes  results  from  unexpected  movements  of  the  palate 
muscles.  It  also  makes  it  possible  to  tie  each  suture  immediately, 
and  saves  the  necessity  for  caring  for  the  free  ends  of  the  sutures 
which  are  more  or  less  in  the  way  if  all  the  sutures  are  passed  before 
any  of  them  are  tied.  By  following  the  silver  plate  that  is  passed 
over  the  free  end  of  the  suture  with  four  perforated  shot  the  first  one 
may  be  clamped  at  once,  and  later  as  the  parts  yield  in  the  course  of 
progress  of  the  suturing,  or  as  the  need  of  still  greater  tension  relief 
becomes  more  apparent  the  suture  can  gradually  be  tightened  by 
clamping  the  second  and  if  necessary  the  third  shot,  still  leaving  the 
'fourth  one  for  final  more  accurate  adjustment  at  the  end  of  the  opera- 
tion. If  silkworm  gut  be  used  for  this  purpose  instead  of  wire,  care 
must  be  taken  when  clamping  the  last  shot  not  to  cut  the  gut  at  the 
silver  plate  by  too  much  compression. 

Exact  adjustment  in  suturing  the  uvula  favors  proper  alignment 
of  the  pharyngeal  muscles.  This  is  essential  because  the  outline 
of  the  faucial  pillars  is  an  important  speech  factor.  Interrupted 
sutures  are  used  well  back  into  the  tissues  and  care  exercised  not  to 
tie  them  too  tightly  otherwise  strangulation  necrosis  may  result.  The 
intervening  gut  sutures  are  placed  nearer  to  the  border  of  the  palate 
to  favor  closer  coaptation  and  where  eversion  of  the  mucous  membrane 
shows  unprotected  tissue  along  the  line  of  coaptation,  horse  hair 
inserted  with  very  fine  needles  is  used  to  complete,  if  possible,  an  abso- 
lutely water-tight  line  of  approximation  throughout. 

Some  operators  depend  upon  mattress  sutures  to  relieve  tension, 
and  depend  upon  a  continuous  suture  for  approximation.  Sinclair 
Kirk  advocates  the  use  of  a  continuous  suture  of  No.  1  or  2  silkworm 
gut  and  claims  that  it  facilitates  rapid  insertion  and  relieves  the 
obvious  necessity  for  great  care  to  insert  the  stitches  opposite  each 
other  and  to  tie  the  sutures  with  a  great  amount  of  tension.^ 

The  author  has  seen  beautiful  results  secured  by  Berry  who  supple- 
ments a  mattress  suture  by  passing  it  through  two  short  pieces  of 
rubber  tubing  which  are  fixed  upon  each  side  close  to  the  junction  of 
the  hard  and  soft  palates. 

Brophy  wires  two  lead  plates  into  position  for  the  same  purpose 
and  countless  other  expedients  have  been  tried  to  overcome  the  ten- 
dency of  palatal  tissue  to  separate  unless  supported  in  the  right  posi- 
tion for  a  suflBcient  period  of  time  to  establish  a  dependable  line  of 
union. 

A  ribbon  of  tape  adjusted  to  encircle  the  flaps  and  overcome  their 
tendency  to  separate,  as  formerly  advocated  by  Mayo,  and  modified 
by  Sherman,  are  efforts  in  the  same  direction. 

It  is  inadvisable  to  cover  large  surfaces  of  the  palate  by  the  use  of 

1  Note  on  Cleft  Palate  Operations,  British  ed.  Jour.,  December  21,  1910.  Berry 
and  Legg:  Harelip  and  Cleft  Palate,  p.  215. 


616 


SURGERY  OF  THE  MOUTH  AND  FACE 


tape,  metal  buttons,  or  plates  or  other  similar  devices  for  relieving 
tension,  because  if  the  parts  cannot  be  brought  into  approximation 
without  undue  tension  the  suture  will  cut  through  in  spite  of  the 
surface  protection,  and  necrosis  will  result  from  undue  compression 
of  any  nature.  The  accumulation  of  debris  is  unavoidable  in  the 
buccal  cavity  under  these  circumstances,  therefore  the  best  cleanli- 
ness is  impossible,  and  local  infection  is  much  more  likely  to  result 
than  if  the  parts  were  left  more  freely  exposed.  Inasmuch  as  a  small 
opening  in  the  central  portion  of  the  palate  may  sometimes  occur  in 
spite  of  every  care,  it  seems  to  be  the  part  of  wisdom  to  keep  the 
sutures  as  independent  of  each  other  as  possible,  so  that  the  condi- 
tions of  the  healing  process  later  on  may  favor  the  filling  in  of  such 


Fig.  394. — Cast  of  the  mouth  of  a 
child,  showing  the  contraction  and  loss 
of  teeth  from  a  compression  in  early 
infancy  operation  and  the  loss  of  tissue 
which  makes  closure  exceedingly  difficult. 


Fig.  395. — Drawing  from  the  cast  of 
the  mouth  of  a  young  woman,  aged 
twenty-eight  years.  Palate  was  closed  by 
compression  in  early  infancy.  Her  upper 
dental  arch  is  so  narrow  and  the  palate  so 
high  that  the  freedom  of  the  tongue  in 
speech  is  so  inhibited  as  to  make  good 
speech  sounds  practically  impossible. 
She  has  also  a  corresponding  contraction 
of  the  nares  with  marked  deflection  of 
the  septum. 


defect  by  granulation  rather  than  the  extension  of  the  breach  in  the 
line  of  union  by  the  loss  of  integrity  which  might  result  if  one  continuous 
sutm-e  were  depended  upon. 

Postoperative  Trsatment. — The  less  the  palate  tissues  are  disturbed 
after  operation  the  better.  The  struggling  and  crying  of  a  child  dur- 
ing mouth  cleansing  manipulations  often  does  more  damage  to  the 
palate  than  the  microorganisms  which  might  or  might  not  be  con- 
trolled by  this  procedure  are  likely  to  do  harm.  A  skilful  nurse  may 
take  advantage  of  the  opportunities  offered  when  the  child  cries  from 
any  cause  to  observe  the  condition  of  the  palate  sutures.  When  treat- 
ment is  required,  with  all  things  prepared  in  advance  to  avoid  delay 
which  may  prolong  the  period  of  struggle,  the  child  is  held  firmly  and 
the  necessary  portions  of  the  mouth  touched  lightly  with  applicators 


CLEFT  PALATE  617 

dipped  in  dioxogen  for  cleansing  purposes.  If  the  accumulation  of 
secretions  in  the  nose  or  other  disadvantageous  conditions  are  indi- 
cated by  the  odor  of  the  child's  breath  and  the  color  of  the  palate 
tissue  the  infant  is  then  placed  face  downward  and  its  nose  flushed 
two  or  three  times  with  a  solution  of  boric  acid.  This  must  be  done 
quickly  and  should  not  be  done  at  all  unless  absolutely  required. 
Attention  should  be  given  to  improving  general  rather  than  local  con- 
ditions. The  gut  sutures  are  allowed  to  absorb  without  interference. 
The  silver  plates  and  tension  sutures  are  removed  on  the  fourteenth 
day.  In  adult  cases  there  is  always  the  disadvantage  of  chronic  nasal 
disease  to  combat,  and  usually  the  nasal  accessory  sinuses  are  also 
in  a  more  or  less  unhealthy  state.  These  secretions  deprived  of  their 
former  drainage  through  the  open  palate  fissure  sometimes  accumulate 
upon  the  upper  raw  surface  of  the  palatal  flaps  and  become  a  serious 
menace  to  the  integrity  of  this  tissue.  To  favor  their  accimiulation 
upon  the  posterior  wall  of  the  pharynx  rather  than  above  the  palatal 
flaps  in  the  newly  fashioned  floor  of  the  nose,  patients  are  kept  lying 
on  their  backs  as  much  as  possible  for  a  sufficient  time  to  insure 
complete  union. 

There  are  serious  disadvantages  in  connection  with  the  use  of  fluids 
for  cleansing  or  antiseptic  purposes  in  this  region.  It  is  therefore 
advisable  to  use  some  suitable  non-irritant  antiseptic  ofl  preparation 
blown  into  the  nose  and  mouth  with  a  nebulizer  which  vaporizes  it. 
This  is  done  frequently  not  only  for  the  purpose  of  controlling  patho- 
genic microorganisms  but  also  to  prevent  bacteria-laden  secretions 
from  clinging  to  the  exposed  raw  tissue  surfaces.  The  oral  surface 
of  the  palate  is  kept  cleansed  by  touching  it  "^-ith  applicators  dipped 
in  dioxogen.  The  lips,  teeth  and  tongue  are  treated  in  the  same 
manner.  Liquid  sterile  nourishment  is  given  by  spoon  and  the  patient 
is  instructed  to  learn  to  swallow  with  as  little  movement  of  the  phar\Ti- 
geal  muscles  as  possible.  It  is  well  to  prevent  speech  effort  at  this 
time  and  to  provide  a  pad  and  pencil  to  serve  the  purpose  of  communi- 
cation without  speech. 

The  battle  in  palate  cases  comes  as  a  rule  between  the  fourth  and 
eighth  days  and  it  is  the  necessary  protection  during  this  period  toward 
which  operative  or  postoperative  efforts  must  be  directed. 

Surgical  Correction  of  Postoperative  Palate  Defects.- — The  most  com- 
mon defects  found  in  palates  that  have  been  preA"iously  operated  upon 
T\-ithout  complete  success  are  sho^^Ti  in  Figs.  394  to  397.  The  most 
diflicult  conditions  to  contend  with  are  found  among  individuals  who 
have  been  operated  on  in  early  infancy  by  compression  to  force  the 
maxillary  bones  together.  In  addition  to  such  defects  as  those  shown 
in  the  illustrations  they  almost  invariably  have  serious  nasal  defects 
also,  and  often  give  a  history  of  middle  ear  and  mastoid  affections  as 
weU  as  mouth  irregularities  due  to  contracted  palates  and  the  loss  of 
tooth  germs  through  the  insertion  of  the  retaining  wires.  The  treat- 
ment of  these  mouths  natiu-afly  involves  questions  which  pertain  to 
health,  as  well  as  speech  and  nasal  deformity.     Continued  patient 


618 


SURGERY  OF  THE  MOUTH  AND  FACE 


Fig.  396.  —  Illustration  prepared  to 
represent  as  nearly  as  possible  the  unequal 
division  of  the  soft  palate  which  has  re- 
sulted from  the  destructive  process  fol- 
lowing imperfect  early  operations,  and 
which  makes  operative  conditions  much 
more  difficult. 


Fig.  397. — Illustration  representing  the 
condition  of  the  mouth  of  a  boy,  aged 
twelve  years.  His  first  operation  was  per- 
formed in  infancy.  Following  this  several 
other  unsuccessful  operations  were  made 
in  attempt  to  close  the  palate  fissure  be- 
fore he  came  under  the  author's  care.  The 
unequal  muscular  activity  had  been  mili- 
tating against  success.  This  fibrous  band 
of  tissue  was  freed  with  the  underlying 
periosteum  and  muscular  readjustment 
accomplished  when  these  openings  were 
closed.  The  result  is  that  at  hia  present 
age,  seventeen,  this  young  man  can  speak 
almost  without  the  slightest  trace  of 
speech  defect. 


Fig.  398. — Drawing  of  the  palate  of  a  young  woman,  aged  twenty  years,  whose  faucial 
pillars  were  injured  in  the  course  of  a  tonsil  operation,  shows  shortening  and  deflection 
of  the  palate,  fluids  escaped  through  the  nose  in  swallowing  and  speech  very  imperfect. 


CLEFT  PALATE 


619 


effort  following  the  lines  of  established  methods  of  palate  operation 
will  finally  result  in  the  complete  closure  of  all  such  postoperative 
palatal  defects,  and  when  the  palate  is  closed,  expansion  of  the  dental 
arches  can  do  much  to  restore  both  cosmetic  appearance  and  phonation. 
Phonation. — In  this  relation  it  must  be  remembered  that  there  are 
many  speech  influences  other  than  those  which  directly  concern  the 
functional  activity  of  the  palate.  The  mechanism  of  speech  involves 
not  only  the  perfect  anatomical  cooperation  of  the  vocal  cords,  the 
respiratory  muscles,  the  auditory  apparatus,  and  the  sound  governing 
influences  of  the  nose  and  nasal  accessory  sinuses  as  well  as  the  tongue, 
teeth,  lips,  cheeks  and  pharyngeal  muscles,  but  the  nerve  control  of  all 


Fig.  399. — Same  case  after  operation. 


these  elements  as  well.  It  therefore  follows  that  the  most  successful 
method  must  be  one  that  favors  pharjTigeal  development  which  will 
give  the  best  form  to  these  anatomical  parts  and  also  the  nervous 
conditions  which  control  their  physiological  activities. 

With  infants  of  sound,  mentality  whose  palates  have  been  closed 
before  speech  habits  have  been  acquired  there  should  be  good  phona- 
tion if  the  form  and  muscular  alignment  of  the  palate  is  sufficiently 
perfect.  When  this  result  is  not  secured  it  is  because  there  has  been 
some  interference  with  the  natural  form  of  the  dental  arches,  the  nose 
or  palate  or  the  palatal  muscular  alignment  has  not  been  sufficiently 
perfect.    In  cases  operated  upon  after  speech  habits  have  been  acquired 


620  SURGERY  OF  THE  MOUTH  AND  FACE 

as  in  older  children  or  adults  there  should  be  some  noticeable  improve- 
ment immediately  following  the  palate  closure,  and  they  may  speak 
with  less  effort,  but  the  defective  speech  sounds  due  to  early  acquired 
wrong  speech  habits  will  not  be  overcome  immediately.  Benefit  in 
this  respect  depends  upon  training  and  the  improvement  which  usually 
follows  in  the  course  of  time.  This  may  be  due  to  conscious  or  uncon- 
scious influences.  There  can  be  no  doubt  of  the  beneficial  possibilities 
of  the  postoperative  speech-training  of  these  individuals,  but  the 
simpler  the  method  used  in  this  direction  the  better  it  will  be  for 
accomplishing  improvement. 

The  author's  observation  leads  him  to  believe  that  the  more  perfectly 
the  palate  may  be  adjusted  and  the  more  natural  the  true  speech  rela- 
tion of  nose,  palate,  tongue  and  pharynx  may  be  approximated  the 
less  need  there  will  be  of  speech-training  and  the  more  perfect  the 
final  speech  result  will  be.  Perfection  in  palate  form  is  of  paramount 
importance,  and  more  often  determines  the  speech  results  following 
cleft  palate  operations  than  the  speech  habit  difficulties  which  have 
hitherto  been  considered  of  first  importance. 

The  editor  has  found  it  possible  for  children  who  had  so  thoroughly 
established  faulty  habits  of  speech  before  the  operation  that  it  seemed 
impossible  for  them  to  change,  to  acquire  perfect  speech  by  employing 
the  following  plan:  In  families  with  means  the  child  was  placed 
among  children  speaking  a  different  language,  which  was  easily  accom- 
plished by  having  the  child  taken  to  a  foreign  country,  it  being  under- 
stood that  whoever  accompanied  the  child  must  also  invariably  use 
the  foreign  language.  After  using  a  foreign  language  exclusively  for 
one  year  or  longer  the  child  will  relearn  its  own  language  without  its 
former  defects. 

In  the  case  of  poor  people  it  is  usually  possible  to  have  the  entire 
family  make  use  exclusively  of  the  language  of  the  country  from  which 
they  have  emigrated,  but  in  this  case  it  is  necessary  to  eliminate  the 
child's  former  playmates,  which  can  be  most  easily  accomplished  by 
a  change  of  residence. 

The  Surgical  Correction  of  Palatal  and  Pharyngeal  Defects  Following 
Tonsil  Operations. — Partial  Paralysis. — Impairment  of  the  motor  ener- 
vation of  the  muscles  of  the  velum  and  the  pharynx  which  occasion- 
ally follows  operative  procedures  in  this  region  may  have  a  tendency 
to  correct  itself  in  the  course  of  time  through  reestablishment  of  the 
nerve  supply.  The  loss  of  tissue  from  the  faucial  pillars  and  the  velum 
not  infrequently  results  from  extensive  sloughing  through  infection 
following  tonsil  operations.  This  also  occurs  through  the  unintentional 
removal  of  portions  of  the  palatoglossus. or  palatopharyngeal  muscles 
by  the  cutting  across  of  one  or  both  of  these  pillars  in  the  course  of 
operations  in  this  region.  In  these  cases  the  soft  palate  is  drawn  to 
the  opposite  side  and  greatly  shortened  through  contraction  upon  the 
side  of  the  injury.  The  effect  is  most  distressing  inasmuch  as  there  is 
a  tendency  for  liquids  to  come  through  the  nose  in  attempts  to  swallow 
and  speech  becomes  markedly  defective.    (See  Figs.  398  and  399.) 


CLEFT  PALATE 


621 


Atresia  of  the  Palatopharyngeal  Opening. — ^Adhesion  of  the  soft  pal- 
ate to  the  posterior  wall  of  the  pharynx  may  result  from  syphilitic 
ulceration  or  from  the  destructive  activities  of  other  infections.  The 
same  condition  may  also  result  from  unskilful  operations  for  the 
removal  of  tonsils  through  the  creation  of  raw  surfaces  which  may 
come  into  apposition  and  lead  to  partial  or  complete  closure  of  this 


Fig.  400. — Atresia  of  the  palatopharyngeal  opening.  Case  of  a  boy,  aged  nine  years. 
The  soft  palate  was  adherent  to  the  posterior  wall  of  the  pharynx  on  the  right  side,  a 
very  slight  opening  being  left  upon  the  left  side.  A  number  of  attempts  to  correct  the 
trouble  resulted  in  failure,  among  these  being  the  ill-advised,  though  sometimes  recomm- 
ended attempt  to  transplant  mucous  membrane  to  cover  the  raw  posterior  surface  of  the 
palate.  Such  efforts  in  these  cases  are  useless.  Mucous  membrane  does  not  transplant  well, 
the  tissues  are  always  distorted  when  the  incisions  are  made  so  that  perfect  coaptation  is 
impossible,  and  there  is  always  infection  to  attack  the  transplanted  tissue.  During 
several  years  of  enforced  mouth-breathing,  nasal  disease  had  become  marked,  the  nares 
narrow  and  the  septum  deflected.  As  a  first  step  the  maxillse  were  separated,  the  nares 
thus  enlarged,  the  deflected  septum  relieved  and  more  healthful  nasal  conditions  secured. 
Following  this,  operation  was  performed  as  shown  in  the  illustration,  with  complete 
relief. 

portion  of  the  post-nasal  space.  The  accumulation  of  nasal  secre- 
tions in  the  pouch-like  form  of  the  nasal  pharynx  thus  established  and 
the  ill  effect  of  this  upon  the  associated  parts  as  well  as  the  defective 
speech  which  is  unavoidable  under  these  conditions  all  combine  to 
render  this  condition  extremely  troublesome.  Figs.  400,  401  and  402 
illustrate  operative  procedures  that  the  author  had  devised  and  found 
exceedingly  useful  in  these  cases 


622 


SURGERY  OF  THE  MOUTH  AXD  FACE 


^ — A 

W1 

^ 

1 

^ 

|, 

m 

% 

/'  /  ni 

JL^flH 

i 

k 

Fig.  401.— The  same  case  as  in  Fig.  400,  after  correction.     The  usefulness  of  the  parts 
in  swallow-ing  and  speech  was  completely  restored. 


Fig.  402. — Illustration  of  the  pharyngeal  opening  of  a  child,  aged  six  years,  resulting 
from  a  tonsil  operation.  The  soft  palate  on  both  sides  in  this  case  is  adherent  to  the 
pharyngeal  wall.     The  small  opening  just  under  the  uvula  is  shown. 


FRACTURES  OF  THE  JAWS 


623 


Fig.  403. — Radiogram  of  the  mouth  of  a  young  man,  aged  twenty-two  years,  with 
cleft  of  the  hard  and  soft  palates.  Shows  the  appearance  of  an  open  palate  fissure  in  a 
radiogram. 


Fig.  404. — Radiogram  of  the  palate  of 
a  young  woman,  aged  twenty-six  years, 
for  whom  an  acquired  opening  in  the  an- 
terior portion  of  the  hard  palate  and  in 
the  soft  palate  due  to  syphilitic  ulceration 
was  closed  in  January,  1913.  By  com- 
parison with  Fig.  403,  taken  with  an  open 
palate  fissure,  the  bone  development  may 
be  appreciated. 


Fig.  405. — Radiogram  of  the  palate  of 
a  young  man,  aged  twenty-two  years, 
taken  six  years  after  the  fissuie  was  closed 
with  mucoperiosteal  flaps  so  adjusted  that 
the  periosteum  was  preserved  in  its  nor- 
mal relation  to  surrounding  parts.  By 
comparison  with  Fig.  403,  taken  with  the 
fissure  in  the  palate  open,  the  bone  de- 
velopment is  more  clearly  understood. 


FRACTURES   OF   THE   JAWS. 

The  varieties  of  jaw  fracture  as  in  other  bones  are  classified  as 
simple,  compound,  multiple,  coviminuted,  and  complicated;  impacted, 
incomplete,  green-stick,  pathological,  when  due  to  preexisting  disease; 
subperiosteal,  as  sometimes  found  in  cases  of  young  children  when 
fracture  of  the  bone  does  not  include  separation  of  the  overlying 
periosteum ;  intrauterine,  when  by  reason  of  a  weakend  osseous  system 
the  offspring  of  mothers  affected  by  scurvy,  syphilis  and  similar  dis- 
ease may  suffer  fracture  before  birth.  In  alveolar  fractures  the  alveolar 
process  is  split  or  fractured  without  involving  other  portions  of  the 
maxillary  bones.  Fractures  are  further  described  as  recent,  old,  united 
and  ununited. 

Etiology. — ^The  superior  maxillce  are  so  surrounded  and  supported 
by  the  other  facial  bones  that  they  are  seldom  fractured  in  civil  life 


624 


SURGERY  OF  THE  MOUTH  AND  FACE 


except  through  some  more  or  less  unusually  forcible  injury  as  a  fall 
from  some  height.  Automobile,  motor  cycle  and  railway  accidents, 
horse  or  man  kicks,  machinery  accidents,  gunshot  wounds,  etc.,  occa- 
sionally produce  fractures  of  this  bone.  Comminuted  fractures  are 
therefore  usual  in  these  cases. 

The  inferior  maxilla  is  more  exposed  and  much  more  subject  to 
fracture  than  its  superior  associate.  The  weakest  point  in  a  normal 
lower  jaw  is  slightly  anterior  to  the  mental  foramen  and  in  an  edentu- 
lous jaw  at  or  in  line  with  the  mental  foramen.  Fractures  in  the 
region  of  the  third  molar  teeth  frequently  occur  as  a  result  of  ill 
advised  efforts  to  extract  these  teeth.  This  is  the  only  unusual  factor 
in  fractures  of  the  jaws  when  compared  with  other  bones. 


Fig. 


406. — Fracture  of  tooth  and  jaw;  tooth  becomes  infected  and  must  be  removed. 

(Dunning.) 


Symptoms. — The  objective  s\Tnptoms  are  deformity,  unnatural 
mobility,  crepitus,  loss  of  function,  increased  salivation.  The  subjec- 
tive indications  are  pain  on  attempting  movement,  tenderness  to 
pressure  at  the  point  of  fracture,  inability  to  speak  and  swallow  with- 
out difficulty.  In  diagnosis  it  will  be  noted  that  the  teeth  are  out  of 
alignment,  there  is  unusual  movement,  and  crepitus  as  the  bone  ends 
are  rubbed  against  each  other.  The  value  of  the  a:-ray  as  a  diagnostic 
aid  in  these  cases  is  shown  in  Figs.  406  and  407. 

Treatment  of  Fractures  of  the  Maxillae. — The  methods  of  retaining 
fractured  lower  jaws  are  as  follows:  (1)  By  bandaging  alone;  (2)  by 
ligating  teeth  upon  each  side  of  the  fracture  as  first  done  by  Hippocrates 
and  used  in  one  form  or  another  ever  since;  (3)  by  splints  constructed 
of  metal,  plaster  of  Paris,  or  other  suitable  material  laid  upon  the 
external  surface  of  the  chin,  the  side  of  the  jaw  or  behind  the  angle 
with  a  few  layers  of  cotton  pad  to  prevent  irritation  and  firmly  band- 
aged; (4)  by  interdental  splints,  i.  e.,  supports  placed  between  the 
jaws,  a  method  first  used  by  Hayw^ard  in  1858  and  modified  and 
improved  by  Gunning  in  1861;  (5)  by  attachments  to  or  upon  the 


FRACTURES  OF  THE  JAWS  625 

teeth  of  the  affected  jaw  only;  (6)  by  wiring  the  teeth  of  both  jaws 
together;  (7)  by  wiring  the  bones,  of  which  a  successful  case  was 
reported  by  Buck,  1847;  (8)  by  bone  plates. 


Fig.  407. — Fracture  of  condyle  showing  partial  dislocation.     (Dunning.) 

In  deciding  upon  the  splint  or  appliance  that  may  be  used  to  hold 
the  fractured  bony  parts  in  position  there  are  certain  important  prin- 
ciples which  must  be  kept  in  view  to  govern  selection.  These  in  the 
order  of  their  relative  importance  are  as  follows:     (1)  Perfect  approxi- 


FiG.  408. — Gunning's  interdental  splint  with  opening  for  introducing  food.  This 
form  of  interdental  splint  may  be  made  of  dental  impression  compound  for  temporary 
purposes  of  vulcanized  rubber  for  permanent  use.  The  jaws  are  held  in  contact  with  this 
splint  by  figure-of-eight  four-tailed  or  other  suitable  bandage. 

mation  of  the  parts;  (2)  immobility;  (3)  freedom  in  taking  nourish- 
ment; (4)  facility  in  keeping  the  mouth  surfaces  clean;  (5)  the  possi- 
bility of  frequent  observation  of  the  parts;    (6)  freedom  in  the  use 

VOL.  I — 40 


626 


SURGERY  OF  THE  MOUTH  AND  FACE 


Fig.  409. — Kingsley's  interdental  splint.  This  gives  fixation  in  upper  jaw  fractures 
with  freedom  of  the  lower  jaw.  The  appliance  is  made  of  vulcanized  rubber  into  which 
wires  that  pass  around  angles  of  the  mouth  and  extend  outside  the  cheek  surfaces  are 
embedded.    To  these  are  attached  elastic  bands  which  pass  over  the  head. 


Fig.  410. — Kingsley's  splint  applied. 


Fig.  411.  —  Dental  splint  applied  to 
cast.  A  continuous  thin  metal  splint 
made  to  fit  over  all  of  the  teeth  in  the 
affected  jaw  and  cemented  into  place. 
This  splint  gives  the  utmost  security  and 
comfort. 


Fig.  412. — Splint  for  fractured  lower  jaw.     (After  Angle.) 


FRACTURES  OF  THE  JAWS  Q21 


Fig.  413.— Splint  for  fractured  lower  jaw.     (After  Angle. 

/ft 


Fig.  414.— Splint  for  fractured  lower  jaw.     (After  Angle.) 


0-  ~r'  N  /-— , 


Fig.  415. — Loher's  splint. 


In  some  forms  of  fractures  all  of  these  desirable  conditions  can  be 
secured,  and  m  others  this  is  impossible.  It  therefore  becomes  necessary 
to  select  the  kind  of  splint  that  will  give  the  greatest  possible  comfort 
to  the  patient  with  the  best  promise  of  a  good  result  by  securing  as 


628  SURGERY  OF  THE  MOUTH  AND  FACE 

shown  in  Figs.  408  to  444. 


Fig.  416.— Bauer's  splint. 


Fig.  417. — Martin's  splint. 


Fig.  418. — Hammond's  splint. 


Temporary  SpKnt-^n  account  of  swelling  and  tenderness  to  touch 
or  because  of  the  critical  condition  of  the  patient  through  other  eftects 
o  the  injury  causing  the  fracture  it  may  be  practically  impossible  o 
adiust  a  splint  with  sufficient  accuracy  to  give  a  sjTBmetrical  result 
Pain  and  other  discomforts  often  demand  an  immediate  fixation  to 
give  the  patient  much  needed  rehef. 


FRACTURES  OF  THE  JAWS 


629 


Under  these  circumstances  the  author  has  found  great  satisfaction 
in  the  appHcation  of  an  interdental  spUnt,  prepared  immediately  with 
dental  impression  compound  which  can  be  softened  in  warm  water, 
quickly  moulded  into  suitable  form  and  then  made  to  serve  the  purpose 
of  a  splint  until  the  improved  local  or  general  condition  makes  it 
possible  to  insert  a  satisfactory  permanent  appliance. 


Fig.  419. — -Shape  of  splint  before  being  fitted 
to  chin.     (Roberts.) 


Fig.  420.— Splint  moulded  to  fit 
chin.     (Roberts.) 


.^Z 


Fig.  421. — Modified  Barton's  bandage.     (Wharton.) 


Army  Temyorary  Splint. — An  improvement  on  this  plan  of  using 
dental  modelling  compound  for  emergency  jaw  splints  is  shown  in  Figs. 
439  and  440. 

Preparation  of  a  Cast  of  the  Mouth  for  Splint  Construction. — In 
constructing  an  interdental  splint  from  a  cast  of  an  impression  of  the 
mouth  the  necessary  disarrangement  of  the  parts  may  be  overcome 
by  sawing  through  the  cast  to  permit  the  correct  adjustment  in  occlu- 
sion of  the  teeth  with  a  cast  of  the  opposite  jaw. 

Kingsley's  Method. — When  this  is  done,  the  splint  will  bring  the  parts 
into  such  position  that  a  good  alignment  of  the  teeth  will  be  assured, 
otherwise  there  may  be  marked  deformity  in  this  respect  after  union 
has  taken  place. 


630 


SURGERY  OF  THE  MOUTH  AND  FACE 


Complications. — In  compound  fractures  of  the  maxillse  there  is  always 
certainty  of  infection  from  microorganisms  in  the  oral  secretions.  In 
other  respects  the  adverse  conditions  which  are  accountable  for  delayed 


Fig.  422. — Emergency  splint  designed  by  Col.  Vilray  P.  Blair  and  adopted  by  the 
U.  S.  Army.     (Courtesy  of  the  Detroit  Dental  Manufacturing  Company.) 


Fig.  423. — A  splint  bent  to  the  required  form  and  filled  with  modelling  compound  and 
ready  for  insertion.     (Courtesy  of  the  Detroit  Dental  Manufacturing  Company.) 


Fig.  424. — Riley's  appliance  for  chronic  dislocation  of  the  lower  jaw  as  applied  in  the 
case  of  a  wounded  soldier. 


FRACTURES  OF  THE  JAWS  631 

union,  malformation  of  the  parts,  injuries  to  nerves  and  bloodvessels, 
necrosis  from  comminuted  bone  fragments  and  similar  disadvantages, 
are  the  same  as  in  other  fractures. 

The  complications  which  do  not  occur  elsewhere  are  from  the 
devitalization  of  tooth  pulps  through  the  effect  of  traumatic  injury- 
destroying  their  nervous  and  vascular  connections  at  the  apical  ends 
of  the  roots.  This  should  always  be  keep  in  mind.  Over  and  over 
again  the  author  has  found  fistulse  which  would  not  close  delayed 
union  because  pus  followed  the  line  of  fracture,  and  serious  necrosis 
of  the  jaws  which  were  traceable  to  gangrenous  pulps  in  the  teeth 
adjoining  or  associated  with  the  fracture.  The  immediate  extraction 
and  treatment  of  such  teeth  is  absolutely  necessary. 

Ludwig's  angina,  extensive  abscesses  in  the  region  of  the  neck  and 
salivary  fistulee  may  occur  from  the  infection  of  compound  fractures. 
Ankylosis  frequently  results  from  fracture  of  the  condyle. 

Reduction  of  the  Fracture. — Under  favorable  conditions  the  antagon- 
ism of  the  digastric  geniohyoglossus  and  mylohyoid  muscles  upon  the 
one  hand,  and  the  masseter,  temporal,  and  pterygoid  muscles  through 
which  disarrangement  of  the  parts  occurs,  may  be  overcome  with 
little  difficulty,  but  when  the  conditions  are  unfavorable  through 
tense  contraction  of  the  muscles  due  to  irritation,  pain,  extreme 
nervousness  of  the  patient,  swelling  and  other  disadvantages,  it  may 
be  necessary  to  administer  an  anesthetic  in  order  to  secure  accurate 
reduction  of  the  fracture  with  proper  alignment  of  the  teeth. 

Period  of  Fixation. — The  time  required  for  complete  union  to  take 
place  must  be  governed  by  the  conditions  of  the  case.  There  is  neces- 
sarily great  difference  in  this  regard  between  simple  uncomplicated 
fractures  in  favorable  situations  and  those  that  are  compound,  or 
multiple  or  comminuted  and  difficult  to  control.  Infection  also  is  a 
governing  factor  in  this  regard.  The  average  time  during  which  a 
splint  may  be  required  to  be  worn  is  approximately  thirty  days. 

In  cases  of  uncomplicated  fracture  after  the  adjustment  of  a  splint 
such  as  shown  in  Fig.  425  the  author  has  known  patients  to  go  directly 
home  and  eat  a  full  dinner  without  discomfort.  Under  less  advantage- 
ous conditions,  liquid  nourishing  food  may  be  required.  The  mouth 
must  be  washed  with  a  suitable  antiseptic  solution  and  whenever 
possible  wiped  with  applicators  dipped  in  dioxogen.  The  danger  of 
inspiration  pneumonia  should  be  guarded  against  as  well  as  that  of 
general  sepsis.  For  this  reason  wiring  the  jaws  together,  wiring  the 
bones  and  interdental  splints  requiring  bandages  should  be  discouraged 
in  favor  of  splints  that  may  accomplish  fixation  and  yet  give  greater 
freedom  in  the  use  and  treatment  of  the  jaws.  The  removal  of  splint- 
ered portions  of  bone  or  sequestra  may  be  important. 

In  case  the  bone  has  been  severely  fragmented  and  the  soft  tissues 
show  extreme  bruising  it  is  well  to  support  the  patient  in  a  sitting 
position  in  bed  and  to  place  a  sheet  of  rubber  dam  about  the  neck  with 
its  lower  end  in  a  vessel  to  collect  the  irrigating  fluid.  Then  a  glass 
tube  with  a  bulbed  end  is  attached  to  an  irrigation  apparatus  suspended 


032 


SURGERY  OF  THE  MOUTH  AXD  FACE 


from  a  point  above  the  bed  and  normal  salt  solution  is  permitted  to 
enter  the  mouth  in  a  small  continuous  stream  until  the  wound  has 
begun  to  granulate  and  until  the  wound  can  be  kept  clean  by  periodic 
irrigation. 


Fig.  425. — Fracture  of  the  upper  maxilla  extending  from  the  cuspid  upward  and 
backward  to  include  all  the  posterior  portion  of  the  jaw.  The  man  fell  from  a  roof 
of  a  house  and  struck  upon  his  face,  causing  not  only  fracture  but  great  distortion  of  the 
parts.  Splint  shown  in  place,  is  attached  to  the  last  molars  on  the  fractured  side,  one  of 
the  incisors,  and  the  cuspid  tooth  on  the  opposite  side.  These  were  connected  by  metal 
bars  made  adjustable  through  the  use  of  nuts  and  screws  and  the  appliance  cemented 
in  place.  By  turning  these  nuts  an  accurate  adjustment  of  the  parts  was  easilj'  accom- 
plished. In  restoring  the  normal  occlusion  of  the  teeth,  an  improved  facial  appearance 
was  acquired.  Fixation  was  absolute  and  he  was  able  to  eat  solid  food  as  scon  as  the  sore- 
ness resulting  from  the  traumatism  disappeared. 


Fig.  426 


FRACTURES  OF  THE  JAWS 


633 


Fig.  427 


Fig.  428 
Figs.  426,  427  and  428  illustrate  a  case  reported  by  Major  Fernand  LeMaitre.i 
showing  nasal  splints,  supported  by  a  prosthesis  in  the  mouth,  which  were  very  success- 
fully used  to  prevent  nasal  stenosis  and  marked  facial  deformity.  Fig.  426,  appliance 
in  place.  Fig.  427,  the  apparatus  in  detail.  Fig.  428,  the  prosthesis  complete,  with 
parts  assembled. 

1  La  Restauration  Maxillo  Faciale,  par  V.  H.  Kazanjian,  Major,  Harvard  Surgical 
Unit,  February,  1919,  p.  22. 


634 


SURGERY  OF  THE  MOUTH  AND  FACE 


Fig.  429. — The  external  lip  support  consists  of  a  piece  of  gutta-percha  molded  to  the 
lip  and  attached  to  an  irregular  U-shaped  wire.  The  ends  of  the  wire  are  bent  at  right 
angles  and  inserted  in  the  headgear  at  the  temporal  region,  while  elastic  bands  applied 
at  the  level  of  the  ear  cause  backward  pressure  on  the  lip.  In  this  case,  the  median 
wire  is  soldered  to  a  removable  upper  cap  splint  in  order  to  give  the  necessary  security.' 


Fig.  430  Fig.  431  Fig.  4-32 

Figs.  430,  431  and  432. — Case  of  a  man.  the  entire  anterior  part  of  whose  mandible 
was  torn  away  by  war  injury.  Fig.  430,  as  it  was  after  first-aid  operative  treatment. 
Fig.  431,  prosthetic  appliance  inserted  in  the  mouth  to  hold  the  jaw  fragments  apart 
and  over  which  the  soft  parts  were  molded.  Fig.  432,  the  result  of  a  first  corrective 
operation  which  gave  sufficient  restoration  to  make  possible  more  perfect  correction 
of  the  lower  lip  later  on. 


1  La  Restauration  Maxillo  Faciale,  par  V.  H.  Kazanjian,  Major,  Harvard  Surgical 
Unit. 


FRACTURES  OF  THE  JAWS 


635 


The  position  will  prevent  hypostatic  congestion  of  the  lungs  at  the 
same  time  that  the  continuous  irrigation  prevents  inspiration  of  septic 
material. 


Fig.  433. — This  figure  illustrates  the 
effect  of  downward  pressure  from  a 
point  of  attachment  in  the  superior 
maxilla. 


Fig.  434. — This  figure  illustrates  the 
necessary  downward  and  forward  or  pro- 
pulsive force. 


Fig.  435. — This  figure  illustrates  an  appliance  which  has  been  more  or  less  widely 
used  as  designed  by  Villain,  and  can  be  attached  to  plates  in  both  jaws  and  is  capable 
of  exerting  both  downward  and  forward  pressure  while  at  the  same  time  it  permits  a 
reasonable  amount  of  jaw  movement. 

Figs.  433  to  435.' — These  figures  illustrate  the  principles  of  the  treatment  by  Georges 
Villain  of  what  he  calls  post-elevateur  fractures  of  the  mandible,  or  fractures  above 
and  behind  the  attachments  of  the  masseter  muscles,  more  particularly  in  the  region 
of  the  neck  of  the  condyle. 

Fractures  of  the  ramus,  if  not  complicated  and  properly  reduced, 
will  usually  be  held  in  position  by  the  action  of  the  masseter  and  ptery- 
goid muscles  without  the  aid  of  a  splint.  When  both  the  rami  are 
affected,  fixation  of  the  jaw  is  required. 

Fracture  of  the  neck  of  the  condyle  can  be  reduced  and  the  parts  held 
in  position  by  the  extension  of  the  jaw  forward  in  the  horizontal  plane 


Villain,  Georges:     La  Restauration  Maxillo-Faciale,  June,  1917. 


636 


SURGERY  OF  THE  MOUTH  AND  FACE 


and  pressure  from  behind  to  reduce  the  fracture.  The  splint  used 
should  be  one  that  is  capable  of  exerting  propulsion.  Figs.  433,  434 
and  435  illustrate  the  method  of  Georges  Villain,  of  Paris,  for  accom- 
plishing this  purpose. 

Complete  unilateral  obliteration  of  both  condyloid  and  coronoid  processes 
will  only  partially  disable  the  masticating  usefulness  of  the  mandible 
if  the  opposite  side  be  intact. 

War  Injury  Jaw  Fractures  in  Great  Numbers. — ^The  great  number 
of  war  injury  jaw  fractures  that  required  treatment  during  the  recent 
world  conflict  from  gunshot,  shrapnel  or  other  high  explosive  wounds, 
aeroplane  accidents  and  similar  unusual  traumatic  injuries,  resulting, 
as  they  did,  in  an  infinite  variety  of  compound  comminuted  jaw  con- 
ditions, often  with  loss  of  large  sections  of  bone,  have,  by  the  very" 
urgency  of  the  existing  necessities,  brought  forward  many  ingenious 
devices  for  retention  and  fixation  that  are  equally  applicable  to  the 
jaw  fractures  of  civilian  life. 


Fig.  436.- — Appliance  designed  for  cases  in  which  there  is  extensive  loss  of  bone  from 
the  anterior  portion  of  the  mandible  when  no  lower  teeth  are  available  for  purposes  of 
retention.  It  preserves  the  remaining  parts  of  the  mandible  in  an  anatomical  position 
and  also  prevents  undesirable  adhesions  at  the  site  of  injurj'.  After  healing  has  taken 
place  this  splint  is  followed  b\-  one  of  the  types  shown  in  Figs.  437  and  438. i 

Experience  with  hundreds  of  these  cases,  as  the  men  were  returned 
to  L  .  S.  Army  General  Hospital  Xo.  11,  at  Cape  ^lay.  New  Jersey,  and 
at  the  Walter  Reed  Hospital,  Takoma  Park,  Washington,  D.  C.,  from 
all  parts  of  the  European  War  Zone,  has  led  the  author  to  believe  that 
many  of  the  methods  of  retention  and  fixation  thus  originated  are  so 
valuable  as  to  warrant  their  substitution  for  older  methods,  even  though 
the  general  principles  of  their  application  and  construction  may  be 
more  or  less  identical. 

The  association  of  nasal  and  other  facial  bone  displacements  with 
fractures  of  the  maxillae  has  required  splints  that  would  support  all  the 
injured  bones  as  well  as  the  maxillary  structures.  Supplementary 
attachments  to  prosthetic  appliances  in  the  mouth  to  hold  the  over- 

1  La  Restauration  Maxillo  Faciale,  par  V.  H.  Kazanjian,  Major,  Harvard  Surgical 
Unit  No.  11,  November,  1918,  p.  34. 


FRACTURES  OF  THE  JAWS 


637 


lying  soft  parts,  as  well  as  the  maxillge  in  normal  position,  or  to  serve 
as  molds  over  which  the  tissues  could  be  formed  in  plastic  operative 
restoration,  have  also  been  extensively  employed  with  wonderful 
success,  and  are  therefore  entitled  to  reproduction  in  this  relation. 
Examples  of  these  are  shown  in  Figs.  436,  437  and  438. 


Fig.  437. — Appliance  designed  by  Kazanjian  for  cases  in  which  there  is  extensive 
destruction  of  the  mandible  confined  to  one  side.  The  lower  restoration  is  hinged  at 
the  middle  and  after  introduction  to  the  mouth,  is  spread  and  locked  by  a  lingual  bar 
which  rotates  at  one  end.  To  prevent  a  backward  rotating  motion  of  the  plate  in  the 
mouth,  an  artificial  condyle  is  attached,  which  consists  of  a  bar  originating  at  the  palatal 
surface  of  the  upper  molar  region  of  the  upper  plate,  and  a  curved  bar  below  on  the 
lingual  aspect  of  the  lower  plate.  The  upper  bar  is'  allowed  restricted  movement  by 
being  adjusted  in  a  small  tube  while  the  lower  is  fixed.  The  upper  bar  operates  posterior 
to  the  lower;  and  the  curves  of  each  are  designed  to  give  as  free  and  natural  movement 
to  the  jaws  as  is  possible. ^ 

Pseudarthrosis. — The  causes  of  delayed  or  faulty  union  of  fractured 
bones  with  the  establishment  of  fibrous  tissues  between  the  bone  ends 
are  chiefly  imperfect  immobilization,  imperfect  approximation  or  the 
interposition  between  the  bone  ends  of  periosteum,  muscle  or  other 
soft  tissue  and  infection.  The  difficulties  of  securing  complete  fixation 
and  failure  to  secure  good  approximation  are  greatly  increased  by  many 
adverse  factors;  most  commonly,  however,  these  conditions  are  directly 
due  to  loss  of  bone  substance,  edentulous  jaws,  the  situation  and  char- 
acter of  the  fracture.  Septic  conditions  are  frequently  long  continued 
because  of  the  presence  of  devitalized  teeth  or  roots  or  fragments  of 
dead  bone  which  for  some  reason  cannot  readily  be  exfoliated.  In  the 
war  cases  bits  of  shrapnel,  lead  from  bullets,  particles  of  clothing  and 
other  foreign  bodies  that  had  been  driven  into  the  tissues  were  frequent 
causes  of  this  trouble. 


1  La  Restauration  Maxillo  Faciale,  par  V.  H.  Kazanjian,    Major,   Harvard  Surgica 
Unit  No.  11,  November,  1918,  p.  34. 


638 


SURGERY  OF  THE  MOUTH  AND  FACE 


The  treatment  of  pseudarthrosv^  consists  in  correction  of  the  cause  by 
removal  of  foreign  bodies,  dead  bone,  if  present  in  the  tissues,  correct 
approximation,  firm  fixation  and  the  excision  of  fibrous  or  other  inter- 
posing tissue  between  the  bone  ends,  with  sufficient  freshening  of  the 
bone  surfaces  to  favor  prompt  union  when  placed  in  direct  contact  and 
bone-grafting  when  bone  fragment  contact  is  impracticable. 

Complete  Loss  of  Segments  of  Bone  from  the  Jaws. — The  characteristic 
indications  of  the  absence  of  bone  from  the  mandible  are  malposition 
of  the  teeth  in  occlusion  and  the  jaw  drawn  to  the  aft'ected  side  in  addi- 
tion to  the  loss  of  function. 


Fig.  438. — Appliance  (designed  by  C.  H.  Kazanjian)  used  as  a  substitute  for  missing 
portions  of  the  mandible.  It  is  hinged  at  the  middle  to  allow  its  collapse  and  introduc- 
tion into  the  mouth,  and  when  spread  to  position  it  is  locked  by  the  Aoilcanite  section 
carrying  teeth. 

A  wide  diversity  of  opinion  existed  among  surgeons  in  overseas 
hospitals  as  to  the  advisability  or  inadvisability  of  bringing  the  bone 
ends  together  without  regard  to  loss  of  form  and  immediately  suturing 
the  overlying  tissues;  the  arguments  in  favor  of  this  treatment  being 
that  much  danger  of  infection  might  thus  be  avoided  and  the  soldiers 
permitted  to  make  more  prompt  recovery. 

The  opponents  of  this  procedure  held  that  at  all  costs  the  bone 
fragments  must  be  held  as  nearly  as  possible  in  their  right  relation,  so 
as  to  preserve  not  only  the  form  and  occlusion  of  the  jaws  but  also  the 
appearance  of  the  face.  Splints  with  attaclunents  to  keep  the  jaws  in 
alignment,  and  at  the  same  time  to  permit  a  sufficient  amount  of 
freedom  of  movement,  are  illustrated  in  Figs.  439  to  442.  It  is  safe  to 
say  that  the  advocates  of  both  these  methods  were  right  and  both  were 
wrong.  \  Sometimes  one  procedure  would  be  indicated  and  sometimes 
the  other. 


FRACTURES  OF  THE  JAWS 


639 


In  fractures  with  loss  of  a  section  from  the  horizontal  body  of  the 
mandible  close  to  the  ramus  it  was  found  that  such  a  wound  under 
favorable  circumstances  could  be  closed  immediately,  with  much  less 
disarrangement  of  the  occlusion  of  the  teeth  and  other  disadvantages 


Fig.  439  Fig.  440  Fig.  441 

Figs.  439,  440  and  441. — Three  different  types  of  splints  in  the  mouths  of  returned 
soldiers  to  preserve  the  jaw  alignment  in  cases  of  mandibular  pseudarthrosis  due  to 
loss  of  bone  substance.  Fig.  439,  spHnt  attached  to  lower  jaw  with  guide  sliding  outside 
the  upper  teeth  on  the  left  side  with  pseudarthrosis  of  the  mandible  on  the  right  side. 
Fig.  440,  splints  on  both  upper  and  lower  jaws  with  corrective  guide  to  overcome  the 
effect  of  the  loss  of  a  large  section  of  bone  from  the  opposite  side  of  the  mandible.  Fig . 
441,  crowns  on  teeth  of  both  upper  and  lower  jaws  with  hooks  on  the  labial  surfaces  to 
wire  with  the  jaws  together. 


Fig.  442. 


-Schroder's  guide  for  cases  of  mandibular  pseudarthrosis  with  absence  of  a 
section  of  bone  shown  with  the  mouth  open.^ 


to  the  patient  than  might  be  expected  because  of  the  muscular  readjust- 
ment which  takes  place  after  firm  union  has  been  secured.  The  ramus 
is  capable  of  moving  forward  to  a  very  considerable  extent  in  a  natiu-al 
effort  to  correct  the  malocclusion,  providing  it  can  be  allowed  to  slide 


1  La  Restauration  Maxillo  Faciale,  April,  1919,  p.  255. 


Fig.  444  Fig.  445 

Figs.  443,  444  and  445. — (Shown  by  courtesy  of  Lieutenant  McCauley,  formerly  of 

General  Hospital  No.  11,  Cape  May,  New  Jersey,  and  the  Dental  Cosmos.) 


Fig.  446 


Fig.  447 


Fig.  448  Fig.  449 

Figs.  446  to  449. — Illustrations  of  the  case  of  a  soldier  w-ith  loss  of  bone  from  the 
mandible  by  gunshot  wound  in  whose  case  a  bone  graft  according  to  the  Albee  method 
was  inserted  bj^  the  author  and  reported  by  McCauley  and  Worthley  in  the  Dental 
Cosmos  for  May,  1919.  Fig.  446,  radiograph  shomng  bone  destruction  (December  1, 
1918).  Fig.  447,  radiograph  wdth  bone  graft  in  place  (January  15,  1919).  Fig.  448, 
jaw  after  the  graft  has  united  without  the  prosthesis  in  place  (March  10,  1919).  Fig. 
449,  removable  bridge-work  denture  inserted  and  worn  over  the  grafted  surface  after 
firm  union  had  taken  place. 
VOL,  I — 41 


642 


SURGERY  OF  THE  MOUTH  AND  FACE 


forward  outside  of  the  superior  maxillary  without  interference  by  meet- 
ing the  maxillary  tuberosity  on  the  affected  side. 

McCauley  after  experience  with  147  cases  of  fracture,  with  loss  of 
substance  occurring  in  the  body  of  the  mandible  in  which  the  posterior 
fragment  has  been  drawn  forward,  states  that  when  the  ramus  is  intact 
and  the  loss  of  bone  is  from  1  to  3  cm.,  and  if  firm  teeth  are  present 
in  the  posterior  fragment,  it  is  very  easy  to  immobilize  the  parts.  But 
if  no  teeth  be  present  and  the  posterior  fragment  has  not  moved  forward 
of  its  own  accord,  and  if  the  loss  of  bone  be  not  greater  than  3  cm.,  an 
open  operation  should  be  performed  and  the  fragments  drawn  together. 


Fig.  450  Fig.  451 

Fig.  450. — Congenital  fibrous  band  extending  from  the  jaw  to  the  cia\'icle,  causing 
deformity  shown  and  rendering  it  impossible  to  hold  the  head  comfortably  in  an  upright 
position.     The  divided  jaw  was  fixed  with  a  splint  attached  to  the  teeth. 

Fig.  451. — Same  girl  shown  in  Fig.  450.  After  correction  of  the  defect  by  a  transverse 
incision  at  a  point  just  above  the  thyroid  cartilage  through  the  fibrous  band  and  after 
freeing  the  surrounding  tissue  the  skin  was  drawn  from  the  central  portion  of  the  incision 
above  and  below,  upward  and  downward  until  when  brought  together  the  line  of  inci- 
sion was  perpendicular  instead  of  parallel.  A  slight  trimming  of  the  skin  at  each  end 
of  the  suture  line  was  necessary  in  order  to  complete  the  outline  of  the  neck. 


The  advantage  of  immediate  early  closure  when  extensive  soft 
tissue  wounds  are  involved  is,  of  course,  obvious.  In  other  cases  it  is 
necessary  at  all  costs  to  keep  the  bone  fragments  apart  and  in  the  best 
possible  approximation  to  their  normal  situation  in  order  to  conserve 
usefulness  of  function  and  cosmetic  appearance. 

Devices  that  were  used  to  successfully  meet  these  conditions  are 
shown  in  Figs.  439  to  442.  When  healing  had  been  satisfactorily  com- 
pleted and  a  sufficient  time  allowed  to  establish  circulation  of  the  parts 
(many  months  w^ere  often  necessary),  and  after  the  overlying  plastic 
restorations  have  been  sufficiently  completed,  the  proper  remedy  lies 
in  bone-grafting. 

The  pin-and-tube  splint,  shown  in  Figs.  443, 444  and  445,  according  to 
the  author's  experience,  was  found  to  be  the  best  of  all  the  splints  that  in 
infinite  variety  w^ere  found  in  the  mouths  of  the  returned  soldiers  whose 
cases  had  been  treated  in  so  many  different  ways  and  under  such  diver- 
sity of  conditions.    It  permits  opening  the  mouth  in  case  of  vomiting 


FRACTURES  OF  THE  JAWS  643 

during  the  operation,  with  certainty  of  exact  replacement  of  the  parts 
when  the  jaws  are  closed.  It  gives  both  the  extension  and  fixation 
against  contraction,  drawing  the  jaw  to  one  side  that  is  afforded  by 
the  other  forms  of  splints.  It  is  simple,  cleanly  and  efEcient  for  its 
intended  purpose. 

Bone-restoration  may  be  accomplished  by  bone-grafting,  according 
to  the  Albee  methods,  as  shown  in  Fig.  459,  by  inserting  a  bone-graft 
from  the  tibia  containing  all  the  layers  of  bone  and  the  overlying  perios- 
teum, placing  this  graft  in  dove-tails  cut  into  the  jaw  fragments  at 
each  side  and  securing  it  there  with  kangaroo  tendon  sutures,  after 
which  the  overlying  parts  were  closed.  Absolute  immobilization  of  the 
jaw  during  the  period  of  bone  formation  is  required  and  septic  infection 
must  be  avoided.  The  graft  is  placed  through  an  outside  incision  along 
the  jaw.  Careful  dissection  is  required  to  free  the  bone  ends  without 
entrance  into  the  cavity  of  the  mouth.  Such  grafts  are  almost  uni- 
formlv  successful,  as  shown  in  the  author's  cases  illustrated  in  Figs. 
446  to  449. 

Osteoperiosteal  grafts,  which  contain  the  periosteum  and  a  thin  under- 
lying bone  shaving,  have  been  extensiA^ely  and  quite  successfully  used 
for  mandibular  restorations.  Two  and  in  some  instances  three  of  these 
grafts  are  cut  the  size  of  the  required  space  to  be  covered,  with  the  perio- 
steum slightly  larger  than  the  bone-shaving  to  which  it  is  attached. 
One  graft  is  placed  with  the  periosteal  side  tm-ned  inward  and  the  other 
on  the  external  sinface,  with  the  periosteum  outward;  if  a  third  segment 
is  used  it  is  forced  in  between  the  other  two.  They  are  secured  by 
suturing  the  graft  periosteum  border  to  the  periosteum  of  the  bone  to 
be  grafted. 

Le  IMaitre  and  many  other  operators  have  employed  the  method  of 
these  grafts  successfully  in  large  numbers  of  cases.  Figs.  450  and  451 
show  one  of  the  author's  cases  with  a  di\dded  mandible  in  which 
pseudarthrosis  had  existed  for  many  years,  now  united  by  an  osteo- 
periosteal graft. 

Pedicled  flaps  according  to  the  method  of  Cole,  have  much  to  recom- 
mend their  employment  in  suitable  cases.  The  illustrations  shown  in 
Figs.  452  to  458,  through  the  courtesy  of  ]\Iajor  F.  J.  Tainter,  are 
self-explanatory. 

One  hundred  per  cent,  success  is  claimed  for  the  pedicled  bone  graft 
because  of  the  better  blood  supply  afforded  by  the  attached  pedicle. 
^^^len  the  entire  anterior  portion  of  the  mandible  has  been  lost,  respira- 
tion is  often  a  serious  factor  when  a  general  anesthetic  is  administered; 
but  with  the  patient  in  an  upright  position  or  with  the  tongue  held 
forward  this  difficulty  may  be  overcome. 

In  grafting  these  cases  the  Albee  method  of  cutting  a  semicircular 
section  of  bone,  the  upper  border  of  the  ilium  serves  the  purpose  better 
than  any  other  bone  graft.  The  external  plate  and  part  of  the  cancel- 
lated structure  are  included  in  the  graft,  but  the  inner  edge  of  the  bone 
is  left  intact  to  prevent  disturbance  of  muscular  attachments  that  one 
carried  with  the  graft,  and  lend  an  important  blood  supply  that  renders 
the  likelihood  of  failure  negligible. 


644 


SURGERY  OF  THE  MOUTH  AND  FACE 


Fig.  452. — Flap  doubled  up  from  inside  Fig.  453. — Method  of  suturing  the  graft 

below  the  jaw  and  the  fraftiirod  mandible  from  one  side  of  the  lower  border  of  the 

exposed.  mandible. 


Fig.  454. — Suturing  holes  for  the  fixation 
sutures. 


Fig.  455. — The  bone  graft  with  attached 
pedicle  ready  to  be  moved  into  position 
and  sutured. 


Fig.  456. — Graft  and  overlying  muscles 
sutured  in  position. 


Fig.  457. — Wound  closed  ready  for  skin 
STiture. 


Fig.  458. — Skin  flap  sutured. 


FRACTURES  OF  THE  JAWS 


645 


Rib  grafts  may  also  be  successfully  employed  to  supply  lost  bone  to 
the  mandible,  as  recommended  by  Gallic  and  Robertson,  but  those  who, 


Fig.  459. — Diagram  of  a  fractured  lower  jaw  so  badly  shattered  as  to  leave  a  gap 
where  a  proper  position  of  the  remaining  fragments  is  maintained.  This  gap  can  be 
satisfactorily  spanned  and  the  fragments  securely  united  through  the  inlay  method 
with  a  graft  and  gutter  produced  by  twin  motor-saws  adjusted  at  the  same  distances 
apart,  producing  an  accurate  fit  of  the  graft  which  is  held  in  position  by  kangaroo-tendon 
sutures  passed  through  drill  holes  in  jaw  fragments.  This  was  a  frequent  condition  in 
the  late  war,  resulting  from  the  trench  warfare.     (Albee.) 


Fig.  460. — Application  of  the  motor-saw  in  operation  for  closing  gap  in  mandible 
produced  by  gunshot  wound.     (After  Gallie  and  Robertson.^) 


1  Transplantation  of  Bone.     By  W.  E.  GalHe,  M.D.,  and  D.  E.  Robertson,  M.D. 
Toronto,  Journal  of  the  American  Medical  Association,  April  20,  1918,  p.  1134. 


Fig.  461. — Insertion  of  half  of  split  rim  with  smooth  side  toward  the  mouth  cavity. 
(After  Gallie  and  Robertson.) 


Fig.  462. — Completion  of  operation  by  the  placing  of  the  other  half  of  the  rib  in 
contact  with  the  first  half  between  the  ends  of  the  fragments  and  by  the  fastening  of 
all  in  place  with  kangaroo  tendon.     (After  Gallie  and  Robertson.) 


Fig.  463.— Shrapnel  wound  destroying 
outer  wall  of  frontal  sinus.  Deep  depres- 
sion after  healing. 


Fig.  464. — Shows  result  of  insertion  of 
rib  cartilage  transplant. 


FRACTURES  OF  THE  JAWS 


647 


r^^H^^^^^H 

w 

^^^^HP^^' 

^ , 

^' 

x»  ■•«•»•  -' 

■^ 

Fig.  465. — Shows  a  man  with  saddle  nose. 


Fig.  466. — Photograph  of  the  same  ease 
after  the  insertion  of  a  bone  and  cartilage 
graft  taken  from  a  rib  and  inserted  from 
the  inside  of  the  nose  without  external 


Fig.  467. — -Shell  fragment  wound.  Scar 
that  produced  a  serious  case  of  trismus; 
was  relieved  by  an  operation.  Forcing 
jaws  apart  unsuccessful  until  after  opera- 
tion. 


Fi(i.  4.66. — Shows  scar  after  operation; 
jaws  forced  apart.  Double  result  was  ob- 
tained in  this  case ;  disfigurement  removed 
and  trismus  cured.  (Case  operated  by 
the  author,  published  by  McCauley  and 
Worthley  in  the  Dental  Cosmos,  May, 
1919.) 


648 


StlRGERY  OF  THE  MOUTH  AND  PACE 


like  the  author,  are  accustomed  to  employ  tibial  grafts  will  doubtless 
find  them  preferable  under  ordinary  conditions. 

Cartilage  Transplants. — Experience  appears  to  prove  that  bone  placed 
in  soft  tissue  without  contact  with  other  bone  surfaces  quickly  becomes 


Fig.  469. — Plan  of  operation  as  followed  by  the  author  in  the  correction  of  the  case 
as  shown,  a,  illustrates  excision  of  scar;  b,  vdde  undermining  of  tissue;  c,  several  rows 
of  buried  catgut  sutures;  d,  tension  suture  of  silkworm  gut  mth  metal  buttons  laid  on 
adhesive  to  prevent  cutting  and  closure  of  wound  with  horsehair  and  2000  fine  linen. 

porous  and  breaks  down.  Cartilage  receives  no  benefit  from  bone 
contact  if  used  for  a  graft  attached  to  bone,  but  when  transplanted  to 
situations  where  it  may  be  surrounded  by  soft  tissue  or  laid  against 
cartilage  it  adapts  itself  readily  to  the  new  situations,  so  that  results 


NECROSIS  OF  THE  JAWS  649 

are  eminently  satisfactory.  Figs.  375,  376,  463,  464,  465  and  466 
illustrate  the  results  of  cartilage  transplants. 

Trismus. — ^Long  fixation  of  the  jaws  in  closed  position,  as  by  inter- 
maxillary splints  and  ligatm-es,  causes  a  certain  amount  of  stiffness  in 
attempted  movement  at  the  temporomandibular  articulation,  but  this 
usually  disappears  when  jaw  movement  is  restored. 

Dhect  injury  to  the  joint  may,  of  course,  cause  true  ankylosis,  but 
in  by  far  the  great  majority  of  jaw  fracture  cases,  when  this  symptom 
is  present  it  is  due  to  associated  muscular  injury,  which  can  be  remedied 
in  some  instances  by  continued  stretching  of  the  adhesions  by  forcing 
the  mouth  open  with  gradual  increase  of  the  extension  or  plastic  opera- 
tions to  correct  the  restricting  conditions.  Fig.  469  illustrates  such  a 
case  and  the  method  of  its  correction. 


NECROSIS  OF  THE  JAWS. 

Necrosis  of  this  bone  is  due  to  direct  or  to  indirect  infection  due 
to  thrombosis. 

In  necrosis  the  bone  structures  are  usually  more  or  less  simultane- 
ously affected,  but  osteitis  is  recognized  as  aft'ecting  the  compact 
portion  of  the  bone,  and  osteomyelitis  an  infectious  disease  involving 
first  the  bone  marrow  and  central  cellular  parts  of  the  bone. 

Etiology. — Hemorrhage  under  the  periosteum  as  in  scurvy,  purpura 
hemorrhagica,  pernicious  anemia,  and  other  affections  manifested  by 
blood  disorders,  trauma  and  infectious  diseases,  may  cause  necrosis 
through  formation  of  blood  clots  under  the  periosteum,  thus  destroying 
i'S  supporting  and  protective  influences. 

Periostitis. — ^Acute  or  chronic,  simple,  non-infective  or  suppurative 
periosteal  inflammation  may  also  lead  to  bene  inflammations  and  later 
to  necrosis. 

The  table  on  page  650  will  serve  to  give  the  general  surgeon  in  a 
simple  manner  a  more  comprehensive  idea  of  this  subject  than  would 
be  otherwise  possible  in  the  space  that  is  available. 

The  following  etiological  classification  has  been  arranged  with 
special  reference  to  necrosis  of  the  jaws. 

Pathology. — ^The  pathological  changes  that  lead  on  from  periostitis 
or  osteomyelitis  and  the  destruction  of  the  maxillary  bones,  to  the 
formation  of  a  line  of  demarcation  between  the  dead  and  living  bone 
structures,  the  formation  of  a  sequestrum  and  an  involucrum,  is  in  no 
essential  respect  different  from  simflar  processes  in  any  of  the  other 
skeletal  structures.  The  only  distinguishing  pathological  change  that 
may  occur  in  the  course  of  this  affection  in  the  jaws  that  cannot  be 
found  elsewhere  is  due  to  the  destruction  of  tooth  pulps  whereby  the 
teeth  thus  devitalized  may  become  persistently  active  in  the  contin- 
uance and  extension  of  the  destructive  processes. 

In  removing  large  sequestra  from  the  lower  jaw,  every  effort  should 
be  made  to  avoid  injury  to  the  periostemn  and  where  large  sections 
of  the  jaw  have  been  removed,  to  preserve  the  form  of  the  jaw  by 


650 


SURGERY  OF  THE  MOUTH  AND  FACE 


careful  packing  or  by  the  use  of  appliances  attached  to  the  teeth,  if 
this  can  be  done.  Neglect  in  this  regard  leads  to  serious  deformity 
through  the  contraction  of  the  jaw.  But  if  the  parts  are  kept  in 
position  the  bone  regenerating  properties  of  the  periosteum  will  be 
found  to  be  almost  marvellous  in  their  corrective  possibilities.  This 
principle  is  well  illustrated  in  Figs.  470  and  471 . 


Diseases  of  the 
teeth  and  al- 
veolar struc- 
ture 


Devitalized  or  infected  or 
gangrenous  tooth  pulps. 
Dento-alveolar  I  Imperfectly  filled  roots  or  teeth, 
abscess  |  Fractured  roots  of  teeth. 

Implantation,   transplantation,  and   replantation    of 
roots  of  teeth. 
Chronic  pericementitis. 
Pyorrhea  alveolaris. 
Pericemental  abscess. 
Ulcerative  stomatitis. 
Gangrenous  stomatitis. 
Gengrenous  conditions  of  the  buccal  tissues. 


Traumatism 


Injury  to  the  periosteum  with  subsequent  infection. 
Compound  fractures  of  the  jaw  or  of  teeth  or  dislo- 
cation of  roots  of  teeth. 
External  blows,  or  force  causing  the  jaws  to  strike 
forcibly  together,   causing  subsequent  death  and 
infection  of  and  from  tooth   pulps. 
Foreign  bodies  in  the  tissues. 
Extension  of  nasal  disease. 
Empyema  of  the  maxillary  sinus. 
Middle-ear  disease,  furuncle  or  other  inflammatory  affections  of  the  skin  and  soft  tissues 

of  the  face. 
Surgical  operations  upon  the  maxillary  bones. 

{Typhoid  fever. 
Scarlet  fever. 
M       1 
Smallpox. 
Infectious  I  Influenza  (la  grippe^ 

diseases.  |  Tuberculosis 

Syphilis 
Actinomycosis 
Glanders 
Leprosy 

Anemia 
Chlorosis. 


Blood 
disorders 


Predisposing  conditions 

Leukemia 
Pernicious  anemia 
Scur\'y 
Septicemia 
I  Pyemia. 


Inorganic  poisons  < 


Toxic  agents 


Organic  poisons 


Mercury 
Arsenic. 
Phosphorus. 
Lead. 

Corrosive  and  escharoti 
acids  and  alkalies. 

Vegetable  poisons  in  the  form  of  drugs  may  lead 
to  necrosis  by  their  direct  destructive  action 
upon  tissue,  or  secondarily  by  causing  depleted 
conditions  to  the  general  system,  or  inducing 
disease  of  special  organs  which  may  predispose 
to  bone  disease,  as  may  also  animal  poisons, 
such  as  bites  of  venomous  reptiles,  stings  of 
insects,  etc. 


NECROSIS  OF  THE  JAWS 


651 


In  young  children,  the  jaws  are  filled  with  erupting  teeth  and  the 
circulating  resistance  correspondingly  reduced.  For  this  reason 
children  frequently  suffer  extensive  necrosis  of  the  jaws  in  the  course  of 
infections  from  dental  and  oral  diseases  to  which  they  are  subject.  In 
these  cases  it  is  often  difficult  to  decide  whether  developing  teeth  should 


Fig.  470. — Face  of  young  -woman  in  whose  case  nearly  all  of  the  lower  jaw  was  removed 
from  the  ramus  on  the  left  side  to  the  molar  region  on  the  right  for  the  removal  of  the 
mj'soma  shown  in  Fig.  441.  Preser-vation  of  the  periosteum  which  was  permitted  on 
account  of  the  character  of  the  growth  and  retention  of  the  forna  of  the  jaw  during  healing 
process  resulting  in  new  bone  formation  so  that  the  girl  is  now  able  to  wear  a  lower  set 
of  teeth  on  the  newly  formed  jaw  and  is  only  slightly  shorter  on  the  left  side  instead  of 
having  the  great  deformity  that  would  otherwise  have  resulted. 

be  retained  or  removed.  Defective  teeth  that  have  been  almost  wholly 
uncovered  by  the  removal  of  sequestra  of  bone  surrounding  them  some- 
times retain  sufficient  A'itality  to  continue  the  course  of  their  develop- 
ment until  new  bone  is  formed  and  their  eruption  takes  place  in  due 


Fig.  471. — Same  girl  shown  in  Fig.  4  70  before  the  remo^-al  of  the  mj-xoma,  showing 
the  extent  of  the  jaw  involved. 

time.  On  the  other  hand  if  such  teeth  become  devitalized  the  results 
may  be  serious.  The  only  safe  rule  of  procedure  in  these  cases  is  to 
preserve  the  dental  organs  whenever  there  can  be  assurance  that  they 
are  still  vital,  but  to  keep  them  under  observation  so  that  if  their 
vitality  be  lost  they  may  be  removed  before  serious  harm  has  resulted. 


652  SURGERY  OF  THE  MOUTH  AND  FACE 

Sjmiptoms. — The  symptoms  of  necrosis  of  the  jaws  are  necessarily 
modified  by  the  character  of  the  cause.  Traumatic  injury  would  be 
evidenced  by  inflammation  of  the  periosteum  in  common  with  over- 
lying injured  parts.  Infection  from  an  acute  dento-alveolar  abscess 
would  present  the  predominant  symptoms  of  this  affection  during  the 
early  stages.  In  all  the  non-traumatic  cases  there  are  present  the 
symptoms  of  acute  infectious  diseases.  These  vary  greatly  according 
to  the  severity  of  the  infection,  the  resistance  of  the  individual,  and  the 
conditions  governing  the  actual  cause.  There  may  be  chills,  fever, 
prostration,  temperature  ranging  from  101°  to  105°  F.,  or  even  higher, 
with  severe  local  pain  and  great  prostration.  The  toxemia  may  be  so 
rapid  as  to  cause  delirium,  stupor,  endocarditis  and  death,  or  there 
may  be  acute  local  pain  with  but  slight  evidence  of  general  symptoms, 
or  subacute  and  chronic  periostitis,  osteomyelitis,  or  osteitis  may  lead 
to  the  destruction  of  large  areas  of  bone  with  almost  no  serious  objective 
symptoms  and  complete  absence  of  pain,  until  in  due  course  there  is 
formation  of  pus  and  the  final  exfoliation  of  the  bone.  Tenderness  to 
touch  over  a  more  or  less  considerable  area  which  is  marked  by  redness 
is  usually  an  early  sjTnptom. 

Caries  of  bone,  being  a  slower  process,  is  usually  unattended  by  pain- 
ful symptoms  other  than  those  incident  to  acute  infections,  which 
may  be  the  first  cause  of  the  formation  of  the  bone  abscess.  The  most 
common  cause  of  caries  in  the  maxillary  bones  is  dento-alveolar  abscess, 
which,  having  become  chronic,  proceeds  slowly  with  bone  disintegra- 
tion until  considerable  excavations  in  the  bone  have  been  accomplished. 

Diagnosis. — ^Yhen  sequestra  of  bone  have  been  formed  there  is 
usually  discharge  of  pus,  which  by  making  pressure  upon  overlying 
surface  may  be  seen  to  exude  through  several  fistulse.  Touched  with 
a  probe  or  suitable  instrument,  such  bone  will  be  found  to  have  lost  its 
velvety  feeling  and  is  rough.  Usually  slight  motion  of  the  sequestrum 
can  be  detected.  In  carious  conditions  due  to  extensive  and  long- 
continued  chronic  abscesses  the  external  bony  wall  will  usually  be  found 
to  be  extremely  thin  and  yielding  to  pressure.  It  is  this  characteristic 
which  often  serves  to  indicate  the  existence  of  a  carious  area  that  would 
not  otherwise  be  suspected.  Surrounding  bone,  not  yet  fully  disinte- 
grated but  without  normal  vitality,  is  also  recognized  by  its  rough, 
dead  feeling.  Perhaps  in  no  other  part  of  the  body  is  recognition  of  the 
exact  cause  of  necrosis  so  necessary  or  difficult.  The  differentiation 
of  different  diseases  and  forms  of  infection  through  which  the  local 
disease  might  have  been  caused  is  equally  important  in  all  fields  of 
practice,  but  on  account  of  the  multiplicity  of  cause  of  diseases  of  the 
teeth,  and  the  great  variety  through  which  infection  might  occur, 
careful  distinction  is  exceedingly  necessary. 

Treatment  of  Necrosis  and  Caries. — In  the  acute  stages,  when  pain 
and  other  symptoms  of  acute  inflammation  are  present  and  before 
nature  has  had  opportunity  to  complete  the  process  of  separation 
between  dead  and  living  bone,  treatment  is  limited  to  measures  which 
relieve  the  pain,  check  the  progress  of  the  inflammation,  and  if  possible 


NECROSIS  OF   THE  JAWS  653 

abort  the  formation  of  complete  necrosis.  Som'ces  of  infection  or 
irritation  must  be  brought  within  control  or  at  least  receive  appropriate 
attention.  Incision  through  the  overlying  tissues  and  periosteum  down 
to  the  bone  is  the  best  method  to  check  the  progress  of  an  acute  diffuse 
suppurative  periostitis  and  will  greatly  reduce  the  extent  of  necrosis 
in  this  as  in  other  bones. 

When  actual  disintegration  of  bone  has  been  accomplished  the 
treatment  briefly  outlined  is  as  follows: 

1.  Correction  of  the  cause. 

2.  Relief  of  pus.  ' 

3.  Sterilization,  local  antiseptic  treatment  to  prevent  extension. 

4.  Removal  of   Dead   Bone. — Distinction  must  be  made  between ' 
necrosis  and  caries  in  treatment.     No  attempt  should  be  made  at 
removing  sequestrum  until  an  involucrum  has  been  formed  sufficiently 
strong  to  maintain  the  form  of  the  jaw. 

The  sequestrum  or  sequestra  should  be  taken  out  intact  if  possible. 
Carious  bone  must  be  removed  with  a  surgical  or  dental  engine  bur, 
a  chisel,  or  curette,  and  all  roughened  bone  borders  made  smooth. 
This  distinction  is  very  necessary  because  an  attempt  to  get  out  a 
sequestrum  of  bone  with  a  dental  bur  would  only  result  in  breaking 
up  little  particles  of  bone  and  forcing  them  into  the  tissues,  thus 
leading  to  continuation  instead  of  relief  of  the  disease.  After  the 
sequestrum  has  been  removed  the  bone  borders  may  be  smoothed  by 
the  use  of  a  10  to  25  per  cent,  solution  of  sulphuric  acid  or,  better  still, 
with  a  curette,  and  all  carious  bone  removed  until  the  smooth,  velvety 
surface  of  healthful  bone  can  be  recognized. 

5.  Packing. — If  the  cavity  in  the  tissues  remaining  after  the  dead 
bone  has  been  dislodged  or  cut  away,  is  of  such  form  or  situation  as  to 
be  unfavorable  to  drainage,  then  it  may  be  necessary  to  insert  a  packing. 
This  is  best  done  with  gauze,  because  cotton  is  likely  to  leave  threads 
behind  to  continue  irritation  and  infection  afterward.  The  gauze 
should  be  wrung  out  of  some  suitable  antiseptic  solution,  preferably 
5  per  cent,  carbolic  acid,  and  sealed  in  with  collodion  or  gutta-percha 
dissolved  in  chloroform.  Once  each  day  this  should  be  changed  to 
avoid  infection. 

When  the  wound  cavity  can  be  made  sufficiently  open  and  saucer- 
shaped  to  facilitate  natural  drainage  and  prevent  lodgment  of  dis- 
advantageous agents  this  should  be  done,  and  then  no  packing  ought 
to  be  used;  but  the  continued  holding  in  the  mouth  of  dioxogen,  or 
any  of  the  well-known  suitable  germicidal  agents,  must  be  depended 
upon  to  prevent  continuation  of  the  infection.  General  treatment 
is  often  requhed  to  overcome  the  toxic  effect  of  the  disease.  Iron, 
quinine,  cod-liver  oil,  and  tonics  are  often  valuable. 

Diseases  such  as  syphilis,  tuberculosis,  actinomycosis,  leprosy  and 
glanders  must  each  receive  its  own  special  treatment  as  indicated,  in 
addition  to  the  local  treatment. 


MAJOE  OPERATIONS  OF  THE  MOUTH. 


By  albert  J.  OCHSNER,  M.D. 

EPULIS. 

Aside  from  the  surgical  diseases  covered  in  the  preceding  chapter 
we  must  consider  secondary  involvement  of  the  cheek,  tongue,  tonsils, 
palate  and  pharynx,  following  the  development  of  carcinoma  of  the 
jaws  and  especially  the  form  of  tumor  known  as  epulis,  which  begins 
in  the  gums  from  embryonic  tissue  of  a  tooth.  The  condition  is  only 
mildly  malignant  in  its  early  stages,  but  if  only  partially  removed,  or 
if  not  removed  at  all,  the  condition  becomes  more  and  more  malignant. 

Diagnosis. — The  diagnosis  has  been  discussed  in  the  previous  chapter. 
At  times,  however,  the  patient  comes  to  the  surgeon  for  the  first  time 
with  an  indurated  ulcer  of  the  cheek  or  tongue  or  floor  of  the  mouth 
extending  along  the  margin  of  the  teeth,  and  the  patient  gives  a  history 
of  pain  or  irritation  in  the  affected  area  without  being  able  to  state  at 
what  point  the  lesion  first  began. 

The  edges  are  irregular,  somewhat  elevated  and  usually  painful  and 
reddened.  They  may  be  quite  circumscribed,  or  they  may  extend  to  a 
greater  or  less  area  including  any  of  the  surfaces  in,  the  mouth. 

Differential  Diagnosis.— It  may  be  difficult  to  make  a  differential 
diagnosis  between  epithelioma  originating  from  the  mucous  membrane 
or  carcinoma  originating  from  embryonic  dental  tissue  or  syphilitic 
ulcer.  The  latter  condition  should  be  confirmed  or  eliminated  by  the 
history  together  with  a  Wassermann  or  Noguchi  test.  If  there  is  still 
some  doubt,  we  have  seen  some  striking  effects  from  the  use  of  salvarsan 
and  neosalvarsan.  Should  the  condition  improve  to  a  marked  extent 
under  this  treatment,  it  should  be  continued  together  with  the  use  of 
mercury  and  potassium  iodide.  In  case  the  presence  of  syphilis  has 
been  positively  eliminated,  it  is  not  important  to  the  patient  to  deter- 
mine from  which  tissue  the  disease  has  originated,  because  the  treat- 
ment must  be  the  same  in  either  case  and  the  microscopic  examina- 
tion will  determine  the  origin  readily  when  the  excision  has  been  made, 
because  the  microscopic  picture  of  an  epithelioma  shows  the  same  type 
of  cells  that  one  finds  in  the  mucous  membrane  of  the  mouth  as  shown 
in  Figs.  472  and  474,  while  the  other  shows  the  form  of  epithelial  cells 
that  one  finds  in  the  embryonic  tooth,  Fig.  475.  Under  no  condition, 
however,  should  a  small  piece  of  the  growth  be  removed  for  microscopic 
examination  before  operation,  because  this  is  followed  in  many  cases  by 
a  hopeless  metastatic  infection,  or  in  an  infection  of  the  cervical  lymph 
nodes.    In  either  case,  the  prognosis  is  infinitely  worse  than  before  this 

( 655 ) 


C5G 


MAJOR  OPERATIONS  ON  THE  MOUTH 


Fig.  472. — Epithelioma  of  cheek,  showing  characteristic  prickle  cells  originating  from 
the  mucous  membrane.      X  100. 


Fig.  473. — Epithelioma  of  cheek,  showing  typical  pearls  of  epithelial  cells  due  to  process 
of  keratinization.      X  100. 


EPULIS 


657 


useless  step  was  taken,  which  can  at  best  bring  to  the  surgeon  no 
knowledge  which  can  be  of  any  benefit  to  the  patient,  while  it  is  likely 


Fig.   474.- 


-Adamantine  epithelioma,  showing  typical  structure  of  growth   developing 
from  embryonic  structure  of  tooth.      X  100. 


Fig.  475. — Adamantine  epithelioma.      X  100. 


to  do  the  latter  an  irreparable  injury.    Unfortunately,  the  feeling  still 
exists  that  it  is  necessary  to  make  a  positive  scientific  diagnosis  before 


VOL.  I — 42 


658  MAJOR  OPERATIOXS  OX  THE  MOUTH 

the  operation  by  means  of  microscopic  examination,  because  a  number 
of  years  ago  when  only  a  few  surgeons  had  the  facilities  for  making  such 
exammations,  they  came  to  overestimate  its  value  because  it  placed 
them  in  a  different  class  from  their  competitors  and  through  them  the 
literature  was  filled  with  this  vicious  idea.  In  many  instances,  these 
malignant  ulcers  are  preceded  by  leukoplakia  or  psoriasis  linguae. 

TUMORS  OF  THE  TONGUE. 

IMalignant  growths  of  the  tongue  may  occupy  areas  varymg  in  size 
and  location,  making  their  extirpation  difficult  or  easy.  The  funda- 
mental principle  of  making  a  very  extensive  excision  in  removing 
malignant  growths  is  quite  as  important  in  this  region  as  in  any  other, 
although  it  has  been  pointed  out  that  the  blood  supply  of  the  tongue  as 
well  as  the  distribution  of  the  lymph  spaces,  is  fairly  limited  to  each 
lateral  half,  and  that  therefore  recurrences  are  quite  unlikely,  if  a 
malignant  growth  which  is  small  and  circumscribed  and  located  on  the 
lateral  edge  of  the  tongue  is  removed  to  the  midline  of  the  organ.  This 
should  apply  only,  however,  to  cases  in  which  the  growth  does  not  exceed 
1  cm.  in  diameter.  In  case  the  growth  is  more  extensive,  the  entire 
tongue  to  a  distance  of  2  cm.  beyond  the  growth  should  be  removed. 
If  the  growth  is  located  upon  the  upper  surface,  it  is  usually  not  neces- 
sary to  remove  the  lymph  nodes  in  the  neck. 

Methods  of  Operation. — In  case  the  malignant  growth  is  confined  to 
the  anterior  half  of  the  tongue,  the  following  method  is  to  be  preferred : 
A  chromicized  catgut  suture  is  passed  through  the  base  of  the  tongue  by 
means  of  a  curved,  round-pointed  needle,  the  tongue  being  drawn  for- 
ward, the  mouth  being  held  open  by  means  of  a  gag.  Forceps  are 
applied  to  each  end  of  the  suture  and  the  tongue  is  drawn  forward  by 
means  of  this  suture.  Then  a  second  suture  is  placed  through  the  base 
of  the  tongue  1  cm.  behind  the  first  one.  The  tongue  is  then  drawn 
upward  toward  the  roof  of  the  mouth  and  the  lingual  artery  and  veins 
are  exposed  by  means  of  an  incision  through  the  mucous  membrane. 
These  vessels  are  caught  separately  between  two  pairs  of  forceps,  then 
cut  and  then  ligated.  While  an  assistant  pulls  the  tongue  forward  by 
means  of  the  two  sutures  which  were  first  applied,  the  surgeon  grasps 
the  edge  of  the  tongue  and  cuts  away  the  organ  to  a  point  2  cm.  behind 
the  portion  involved,  by  means  of  an  electric  cautery.  There  will  be 
practically  no  hemorrhage  and  the  few  small  vessels  which  were  exposed 
and  which  may  bleed  slightly,  are  caught  by  means  of  hemostatic 
forceps  and  ligated.  Two  chromicized  catgut  sutures  are  then  applied, 
grasping  the  edge  of  the  tongue  and  following  the  cut  surface  at  a 
depth  of  1  cm.  These  are  then  tied,  bringing  the  two  lateral  margins 
together  in  front.  The  mucous  membrane  of  the  superior  and  inferior 
surfaces  is  then  sutured  by  means  of  fine  chromicized  catgut  sutures 
and  the  two  sutures  which  were  first  applied  are  tied  loosely  and  a  large 
pair  of  hemostatic  forceps  is  applied  to  the  free  ends  and  fastened  to  the 
patient's  clothing  by  means  of  a  large  safety-pin.    Occasionalh'  one  of 


TUMORS  OF  THE  TONGUE  659 

these  patients  has  a  spasm  which  causes  him  to  swallow  this  stump  of 
the  tongue,  which  may  press  upon  the  epiglottis  to  such  an  extent  as  to 
endanger  the  patient's  life  from  suffocation. 

In  case  the  involvement  is  so  extensive  that  it  cannot  be  radically 
removed  by  this  method,  it  is  best  to  follow  the  method  introduced  by 
Sedillot  which  has  been  practiced  extensively  by  Kocher  and  his  pupils. 
The  advantages  of  this  method  lie  chiefly  in  the  fact  that  a  very 
extensive  operation  can  be  performed  practically  without  the  loss  of 
blood  and  with  the  greatest  thoroughness  and  the  slightest  amount 
of  traumatism.  This  operation  is  indicated  only  in  case  of  removal  of 
malignant  growths.  Non-malignant  growths,  such  as  cysts,  papillo- 
mata,  lipomata,  tubercles,  can  be  removed  by  the  method  described 
above.  It  is  of  course  important,  in  cases  of  malignant  disease  of  the 
tongue,  to  operate  immediately  upon  making  the  diagnosis,  because  in 
early  operations  the  prognosis,  so  far  as  permanent  cure  is  concerned, 
is  vastly  better  than  in  late  operations. 

Kocher 's  Operation  for  Extensive  Involvement  of  the  Tongue. — ^A  pre- 
liminary operation  is  performed,  consisting  in  removing  all  of  the 
lymph  nodes  of  the  neck  up  to  the  parotid  gland  and  down  to  the 
clavicle  and  forward  along  the  hyoid  bone  and  lower  jaw,  including  the 
submaxillary  salivary  gland  together  with  the  lymph  nodes  surrounding 
this  gland.  The  anterior  facial  vein  and  artery  and  the  external  carotid 
artery  are  ligated  and  severed  on  the  side  on  which  the  malignant 
growth  is  located  in  the  tongue,  or  on  both  sides  of  the  malignant 
growth  approaches  or  extends  beyond  the  middle  of  the  tongue,  except 
that  in  this  case,  the  external  carotid  is  ligated  only  on  the  side  on 
which  there  is  the  greater  amount  of  involvement.  It  is  well  to  per- 
form this  operation  on  one  side  at  one  sitting,  and  then  to  perform  it  on 
the  other  side  a  few  days  later.  In  all  cases  whose  general  condition 
would  indicate  that  the  patient  has  not  a  sufficient  amount  of  resist- 
ance to  withstand,  an  extensive  operation,  it  is  well  to  apply  intensive 
.T-ray  treatments  to  the  side  operated  upon  directly  after  conclusion 
of  the  operation.  The  ear  and  face  should  be  protected  by  means  of 
lead-sheets  and  the  rays  should  be  filtered  through  an  alummum  screen 
1  mm.  in  diameter.  The  lymph  nodes  are  excised  in  accordance  with 
the  methods  described  in  the  chapter  on  Surgery  of  the  Neck. 

After  the  patient  has  recovered  sufficiently  to  make  the  operation 
for  excision  of  the  tongue  safe,  the  following  operation  should  be 
undertaken.  The  patient  receives  a  hypodermic  injection  of  J  grain 
of  morphin  and  -^^^  grain  of  atropin  one-half  hour  before  the  anes- 
thetic is  administered.  The  patient  is  then  thoroughly  anesthetized 
with  ether  by  the  drop  method,  then  a  catheter  No.  40  French  scale 
is  introduced  into  each  nostril  a  sufficient  distance  to  place  its  free  end 
opposite  the  larynx.  The  two  catheters  are  attached  to  a  Y-shaped, 
glass  tube  which  in  turn  is  attached  by  means  of  a  rubber  tube  to  a 
funnel  through  which  ether  may  be  administered  if  this  is  required. 
The  patient  is  then  placed  with  the  head  elevated  so  that  the  body  will 
lie  at  an  angle  of  45  degrees.    The  resulting  anemia  of  the  bram  will 


660  MAJOR  OPERATIONS  ON  THE  MOUTH 

serve  to  keep  the  patient  anesthetized  without  the  further  use  of  ether 
for  a  period  of  nearly  an  hour,  which  is  more  than  sufficient  time  to 
complete  the  proposed  operation.  The  method  is  identical  with  that 
employed  in  anesthetizing  patients  for  the  operation  of  thyroidectomy. 

A  vertical  incision  is  then  made  through  the  lip,  down  over  the  chin 
and  beyond  the  edge  of  the  chin  for  a  distance  of  4  cm.  A  Gigli  saw 
is  then  placed  around  the  inferior  maxilla  and  the  latter  is  sawed 
through  exactly  in  the  median  line.  By  separating  the  two  sections  of 
the  jaw,  one  obtains  a  splendid  approach  to  the  floor  of  the  mouth  and 
the  tongue.  It  is  important  to  preserve  without  injury  the  muscles  in 
the  floor  of  the  mouth  to  the  greatest  possible  extent,  but  this  must  not 
be  done  at  the  risk  of  leaving  tissues  that  have  been  invaded  by  the 
malignant  growth.  All  of  the  invaded  tissues  are  now  cut  away  by 
means  of  the  electric  cautery.  There  will  be  practically  no  hemor- 
rhage, but  any  bleeding  points  which  may  occur,  should  be  caught  in 
forceps  and  ligated  at  once.  Two  cm.  of  healthy  tissue  should  be 
removed  on  each  side.  In  ortler  to  prevent  the  patient  from  inspiring 
mucus,  it  is  well  to  thoroughly  cocainize  the  pharynx  before  the 
anesthetic  is  administered  by  means  of  a  4  per  cent,  cocain  spray,  and 
then  to  place  a  gauze  tampon  in  the  pharynx  to  prevent  the  trickling 
6f  blood  or  mucus  into  the  larynx.  The  preliminary  ligation  and  the 
position  of  the  patient  almost  completely  prevent  the  accumulation 
of  blood  in  this  region,  and  the  administration  previous  to  adminis- 
tering the  anesthetic  of  yg-Q  grain  of  atropin  will  prevent  the  secretion 
of  mucus.  Both  of  these  points  are  important  in  the  prevention  of 
postoperative  pneumonia.  After  all  of  the  diseased  tissues  have  bsen 
removed,  the  surfaces  are  covered  to  as  great  an  extent  as  possible  with 
mucous  membrane  by  means  of  fine  chromicized  catgut  sutures.  Any 
surfaces  which  cannot  be  covered  are  tamponed  carefully  with  iodoform 
gauze. 

During  the  operation,  the  manipulations  can  be  greatly  facilitated  by 
applying  a  spreader  which  will  hold  the  two  halves  of  the  jaw  as  far 
apart  as  possible  without  injuring  the  ligaments  of  the  joints.  Pro- 
vision is  made  to  prevent  swallowing  of  the  stump  of  the  tongue  similar 
to  that  described  above,  by  means  of  applying  two  chromicized  catgut 
sutures  through  the  stump  and  attaching  forceps  to  the  free  ends  of 
these  sutures.  The  two  halves  of  the  jaw  are  then  brought  together;  a 
hole  is  drilled  through  each  and  they  are  carefully  fastened  together 
by  means  of  a  silver  wire.  A  drainage  tube  is  placed  in  the  lower  angle 
of  the  wound  and  the  soft  tissues  are  carefully  united  by  sutures. 

After  the  operation  has  been  completed,  the  patient  should  be  placed 
in  bed,  the  top  of  bed  elevated  to  a  height  of  -40  cm.  and  a  head-rest 
placed  under  the  head  and  shoulders  of  the  patient  so  that  the  latter 
will  be  in  a  semi-sitting  position.  Before  the  operation  is  undertaken, 
the  teeth  should  be  cleansed,  and  the  mouth  washed  with  peroxid  of 
hydrogen,  and  it  is  well  to  spray  the  mouth  several  times  each  day  with 
oil  of  eucah^Jtus  for  the  purpose  of  cleansing  the  tongue.  A  mouth 
wash  of  half  an  ounce  of  chlorate  of  potash  to  the  pint  of  water  is  also 


SURGICAL  DISEASES  OF  THE  TONSIL  661 

very  useful  for  cleansing  the  mouth  preliminary  to  the  operation.  This 
should  be  used  during  the  time  that  elapses  between  the  entrance  of  the 
patient  to  the  hospital  and  the  final  removal  of  the  tongue.  Performing 
the  preliminary  operations  of  ligation  and  removing  the  lymph  nodes  in 
the  neck  will  postpone  the  final  operation  from  ten  days  to  two  weeks, 
but  if  the  mouth  is  carefully  cleansed  by  the  methods  just  described, 
and  if  intensive  .r-ray  treatment  is  employed  for  the  neck  during  this 
period,  it  does  not  seem  as  though  the  patient's  ultimate  results  would 
be  harmed  by  this  postponement  of  the  operation. 

It  seems  important  to  perform  the  actual  removal  of  the  tongue  by 
means  of  the  electric  cautery  rather  than  by  means  of  the  knife,  because 
there  is  great  danger  of  transplanting  carcinomatous  tissue,  and  if  the 
raw  surfaces  are  made  with  the  electric  cautery,  this  calamity  is  less 
likely  to  occur.  In  case  the  carcinoma  has  extended  to  the  jaw  or  to  the 
side  of  the  mouth,  it  is  best  to  remove  all  of  the  diseased  tissue  by  means 
of  the  actual  cautery  and  to  thoroughly  cauterize  the  jaw  after  extract- 
ing the  teeth  in  the  region  involved.  For  this  purpose  ordinary  small 
soldering  irons  heated  in  a  strong  gas  flame,  are  much  more  effective 
than  the  electric  cautery  or  the  Paquelin.  In  case  the  malignant 
growth  has  actually  penetrated  the  jaw,  the  latter  should  be  resected 
to  a  distance  of  2  cm.  beyond  the  infected  area.  It  is  important  in 
all  of  these  cases  to  provide  for  a  free  external  drainage  in  order  to 
prevent  harm  from  accumulation  from  wound  secretion  which  might 
be  inspired  into  the  trachea  and  give  rise  to  pneumonia. 

After-treatment. — There  is  considerable  danger  from  inspiration- 
pneumonia  after  these  operations.  It  is  difficult  for  these  patients  to 
swallow,  and  for  this  reason  it  is  well  to  pass  a  catheter  into  the  esopha- 
gus through  the  nose  and  to  administer  water  and  liquid  nourishment 
through  this  catheter.  It  is  also  wise  to  administer  water  and  con- 
centrated predigested  food  several  times  each  day  by  means  of  proctoc- 
lysis. It  is  most  important  to  keep  the  head  of  the  patient  elevated 
in  a  manner  in  which  he  can  be  comfortable  and  in  which  the  fact  of 
being  held  in  this  position  will  not  cause  him  to  become  exhausted. 

SURGICAL  DISEASES  OF  THE  TONSIL. 

The  diseases  of  the  tonsil  requiring  surgical  operation  are  hyper- 
trophy due  to  chronic  inflammation,  tuberculosis  of  the  tonsils,  chronic 
abscess  of  the  tonsil,  and  acute  abscess.  All  of  these  conditions  are 
likely  to  result  from  an  infection  taking  place  in  the  tonsil  whose 
anatomical  structure  has  been  injured  as  a  result  of  an  inflammatory 
process  occurring  during  scarlet  fever,  measles  or  influenza.  Undoubt- 
edly, the  physiological  function  of  the  tonsil  may  become  so  thoroughly 
impaired  as  a  result  of  the  inflammation  accompanying  these  diseases 
that  the  organ  is  no  longer  able  to  protect  its  owner  against  infectious 
material  passing  over  the  area  it  occupies.  The  crypts  on  the  surface 
of  the  tonsil  form  a  convenient  lodging  place  for  pathogenic  micro- 
organisms which  may  be  placed  on  the  surface  in  food  or  in  mucus 


662  MAJOR  OPERATIONS  ON  THE  MOUTH 

from  the  posterior  iiares  passing  over  the  surface.  The  infection  M^ith 
tubercle  bacilli  and  the  secondary  infection  of  the  lymph  nodes  will  be 
considered  in  a  subsequent  chapter. 

Rosenow  and  others  have  directed  attention  to  deep  infection  of  the 
tonsils  with  a  micrococcus  which  is  likely  to  cause  secondary  infection  in 
various  portions  of  the  body  by  a  selective  property  for  the  endothelium 
covering  of  joint  surfaces  especially,  and  giving  rise  to  a  condition 
ordinarily  termed  rhemnatism,  but  which  is  apparently  really  a  form  of 
sepsis,  which  will  be  considered  elsewhere.  The  acute  infections  of  the 
tonsils  may  be  caused  by  any  one  of  a  number  of  microorganisms  the 
most  common  of  which  are,  the  pneumococcus,  the  various  streptococci, 
and  staphylococci,  but  the  infection  is  commonly  mixed. 

If  an  abscess  forms,  producing  what  is  commonly  known  as  quinsy 
sore  throat,  an  incision  should  be  made  through  the  anterior  surface 
of  the  tonsil  in  order  to  permit  the  pus  to  escape.  After  this,  hot 
antiseptic  gargle  should  be  used  until  the  acute  infection  has  subsided, 
and  then  the  tonsil  should  be  removed.  This  should  also  be  done  in 
case  of  chronic  infection  resulting  in  hypertrophy  or  the  presence  of 
deep-seated  small  abscesses. 

Tonsillectomy.- — This  operation  can  be  performed  with  equally  good 
results  by  a  number  of  different  methods.  In  children  it  is  best  to 
perform  the  operation  under  ether  or  gas  anesthesia;  in  adults  it  is 
usually  best  to  spray  the  pharynx  with  a  4  per  cent,  cocain  for  a  period 
of  five  minutes  and  then  to  inject  one-half  of  1  per  cent,  of  novocain  to 
which  two  drops  to  each  10  c.c.  of  1  to  1000  solution  of  adrenalin 
chlorid  has  been  added.  It  is  well  to  use  from  2  to  5  c.c.  of  this  mixture 
for  injecting  each  tonsil,  Avhich  will  cause  it  to  protrude.  After  waiting 
several  minutes,  in  order  that  the  remedy  may  have  the  desired  effect, 
the  upper  pole  of  the  tonsil  is  grasped  by  means  of  a  pair  of  fine-toothed 
forceps  and  the  mucous  membrane  is  cut  with  curved  scissors  or  a  fine 
scalpel  preferably  curved  on  its  flat  surface  about  the  base  of  the  tonsil 
which  is  then  lifted  forward  and  a  wire  snare  is  placed  around  its  base 
and  this  is  tightened  slowly  so  as  to  cut  oft'  the  tonsil  within  its  base. 
If  the  surgeon  has  acquired  much  experience  in  the  use  of  atonsillotome, 
the  same  result  may  be  obtained  in  a  much  shorter  time  by  the  appli- 
cation of  one  of  these  instruments,  provided  the  tonsil  is  drawn  forward 
sufficiently  to  insure  its  complete  removal.  In  children  it  is  sometimes 
desirable  to  cut  oft'  the  outer  half  of  the  tonsil  by  means  of  a  tonsillo- 
tome,  and  then  to  enucleate  what  is  left  of  the  tonsil  down  to  the  capsule 
by  means  of  the  index  finger,  because  in  this  way  the  entire  diseased 
portion  of  the  tonsil  can  be  removed  and  the  loss  of  blood  can  be 
minimized. 

Malignant  Growths  of  the  Tonsil. — Occasionally  one  encounters  an 
epithelioma  of  the  tonsil  in  its  early  stages.  In  this  case,  the  operation 
that  was  first  described  above  for  the  removal  of  infected  tonsils  can  be 
employed  in  the  removal  of  a  tonsil  containing  a  small  malignant 
growth,  but  in  place  of  using  scissors  or  scalpel  it  is  best  to  use  an  electric 
cautery.    In  case  the  carcinoma  is  advanced,  it  is  usually  not  possible 


SURGICAL  DISEASES  OF  THE  TONSIL  663 

to  perform  an  operation  which  will  result  in  a  permanent  cure,  but  if 
this  seems  possible  or  advisable,  the  operation  which  has  been  described 
for  the  removal  of  the  tongue  can  be  employed  for  the  removal  of  cancer 
of  the  tonsil,  with  the  exception  that  the  lymphatics  of  the  neck  will 
have  to  be  removed  only  on  one  side.  It  should,  however,  be  remem- 
bered that  when  the  disease  has  advanced  sufficiently  far  to  make  this 
extensive  operation  necessary,  it  is  almost  never  possible  to  obtain 
permanent  cure. 

In  this  extensive  operation,  it  is  wise  to  sever  all  of  the  tissues  by 
means  of  the  electric  cautery.  It  is  also  wise  to  administer  extensive 
a;-ray  treatments  before  and  after  the  removal  of  these  growths. 
Recently  remarkedly  good  results  have  been  obtained  by  the  use  of 
radium,  using  the  cross-fire  method  of  placing  a  tube  containing  radium 
on  each  side  of  the  neck. 

Carcinoma  of  Other  Portions  Communicating  with  the  Mouth. — In  the 
removal  of  malignant  growths  from  other  portions  communicating 
with  the  mouth,  such  as  the  pharjiix,  the  posterior  nares,  the  uvula,  or 
the  pillars  of  the  fauces,  the  same  principle  must  be  employed  as  in  the 
operations  just  described.  It  is  important  to  secure  free  access  to  the 
surface  to  be  treated,  and  to  make  a  very  free  removal  of  the  diseased 
tissues  together  with  at  least  2  cm.  of  the  surrounding  tissues.  It  is 
wise  to  remove  all  communicative  lymph  nodes  in  the  manner  decribed 
above,  and  also  to  make  preliminary  ligations  in  the  same  manner  and 
to  employ  after-treatment  with  the  a,'-ray.  In  all  of  these  cases,  it  is 
wise  to  perform  the  operation  with  the  body  placed  at  an  angle  of 
45  degrees,  with  the  head  elevated,  and  to  use  the  form  of  anesthesia 
described  above. 

It  is  possible  to  obtain  a  very  good  view  of  the  ca\'ity  of  the  mouth 
and  pharynx  through  a  transverse  incision  recommended  by  Roser, 
extending  from  the  angle  of  the  mouth  dnectly  backward  in  the 
direction  of  the  angle  of  the  jaw,  extending  to  the  edge  of  the  masseter 
muscle.  By  extendmg  the  incision  in  the  skin  a  little  further  back,  the 
edge  of  the  masseter  muscle  may  be  retracted  sufficiently  to  increase 
the  opening  quite  considerably.  Stenson's  duct  remains  entbely  above 
this  incision  and  need  not  be  considered  in  making  the  incision,  but  in 
applying  deep  sutures  in  closing  the  wound,  one  must  bear  the  location 
of  this  structure  in  mind  in  order  not  to  perforate  it  with  the  needle  or 
surround  it  with  the  sutures.  The  maxillary  artery  should  be  clamped 
with  two  pau-s  of  forceps  and  then  cut  and  ligated  in  order  that  the 
field  of  operation  may  not  be  traumatized  unnecessarily  in  attempthig 
to  stop  the  fierce  hemorrhage  which  is  sure  to  occur  if  the  vessel  is 
severed  carelessly. 

There  will  be  no  interference  with  the  nerves  controlling  the  facial 
expression  if  the  above  directions  are  followed.  The  scar  is  always 
somewhat  disfiguring,  but  much  can  be  done  to  reduce  this  by  Ikniting 
the  traumatism  to  the  slightest  possible  amount  and  by  taking  great 
care  in  closing  the  wound  by  first  applying  from  two  to  four  silkworm- 
gut  sutures  grasping  the  entire  thickness  of  the  cheek  down  to,  but  not 


664  MAJOR  OPERATIONS  ON  THE  MOUTH 

through  the  mucous  membrane,  then  suturing  the  latter  with  fine 
interrupted  chromicized  catgut  sutures,  then  iniiting  the  laj'er  between 
the  mucous  membrane  of  the  cheek  with  fine  eight-day  catgut,  and  then 
uniting  the  skin  with  horsehair  sutures  drawn  just  tightly  enough  to 
secure  an  accurate  coaptation  of  the  edges,  but  not  sufficiently  tight  to 
cause  even  the  slightest  degree  of  pressure  necrosis.  The  silkworm 
sutures  which  were  first  applied  remain  untied  until  all  of  the  other 
sutures  have  been  applied  and  then  they  are  tied  over  all,  but  also  very 
loosely  to  provide  for  the  edema  which  will  appear.  One  may  tie  these 
sutures  over  a  piece  of  gutta  percha  tissue  folded  upon  itself,  or  one  of 
the  ends  may  be  drawn  through  a  piece  of  fine  rubber  tubing  0.5  cm. 
long  in  order  to  prevent  marking  of  the  skin. 

The  horsehair  sutures  should  be  removed  on  the  third  or  fourth  day, 
the  silkworm- gut  sutures  from  the  sixth  to  the  tenth  day.  The  longer 
these  sutures  remain,  the  better  it  will  be  provided  they  do  not  cut  into 
the  skin. 

This  incision  is  less  formidable  than  Sedillot's  described  above,  but 
it  gives  access  to  only  one  side  of  the  cavity  of  the  mouth  and  the  result- 
ing deformity  as  a  rule  is  more  noticeable  because  every  motion  of  the 
face  pulls  upon  the  resulting  scar  and  directs  attention  to  its  existence. 
Many  of  these  patients  are  very  sensitive  concerning  the  fact  that  they 
have  had  a  malignant  growth  removed,  and  it  is  consequently  wise  to 
discuss  the  matter  of  the  scar  with  the  patient  before  the  operation  is 
undertaken. 

In  case  the  patient  cannot  decide  upon  either  of  these  two  methods 
in  a  case  in  which  a  radical  operation  cannot  be  performed  through  the 
mouth,  the  following  plan  may  be  adopted,  although  it  is  not  nearly  so 
convenient  for  the  surgeon  and  somewhat  more  dangerous  to  the 
patient. 

If  this  method  is  chosen,  it  is  even  more  important  to  have  every 
possible  source  of  infection  from  the  mouth  eliminated,  than  if  any  one 
of  the  other  methods  is  chosen,  because  this  method  contemplates  a 
direct  communication  between  the  mouth  and  the  wound  in  the  neck. 

It  is  wise  to  have  the  mouth  disinfected  as  thoroughly  as  possible 
by  the  use  of  peroxide  of  hydrogen,  a  weak  solution  of  formaldehyde, 
a  saturated  solution  of  chlorate  of  potash  in  water,  spraying  with 
eucalyptus  oil,  and  then  to  have  all  of  the  teeth  mechanically  cleaned 
by  a  dentist  and  all  of  the  infected  roots  extracted  and  the  gums  repeat- 
edly swabbed  with  compound  tincture  of  iodin  for  several  days  before 
the  first  step  of  this  operation  is  undertaken.  Too  much  stress  cannot 
be  laid  upon  these  steps  which  can  usually  be  carried  out  while  the 
patient  is  considering  the  proposed  operation. 

During  this,  the  neck  should  be  exposed  to  daily  .r-ray  exposures. 
Having  decided  upon  this  operation  and  having  accomplished  the 
preliminary  disinfection  of  the  mouth,  ether  is  administered  according 
to  the  method  described  in  the  chapter  on  Surgery  of  the  Thyroid  Gland, 
page  771. 

The  patient  is  placed  in  an  inverted  Trendelenburg  position  with  the 


SURGICAL  DISEASES  OF  THE  TONSIL  665 

head  of  the  bed  elevated  45°.  If  the  patient  is  thoroughly  anesthetized 
with  ether  by  the  drop  method  in  the  horizontal  position  before  being 
placed  in  this  inverted  Trendelenburg  position,  the  resulting  anemia  of 
the  brain  will  keep  him  sufficiently  under  the  influence  of  the  ether  to 
enable  the  surgeon  to  complete  the  operation  without  the  further  use 
of  ether.  The  J  grain  of  morphin  which  was  given  hypodermically 
before  the  operation  was  begun  will  reduce  the  patient's  sensitive- 
ness greatly  and  the  ^io  grain  of  atropin  will  reduce  the  secretion  of 
mucous  in  the  mouth  and  pharynx.  By  following  this  plan,  one  can 
avoid  the  preliminary  tracheotomy  which  has  been  recommended  by 
many  surgeons  for  the  purpose  of  giving  the  anesthetic  through  the 
tracheotomy  cannula.  It  is  also  very  much  to  be  preferred  to  all  of  the 
intratracheal  methods  of  administering  anesthetics  which  have  been 
recommended. 

It  is  an  excellent  plan  to  spray  the  mouth  and  pharynx  thoroughly 
with  a  4  per  cent,  solution  of  cocain  for  a  period  of  about  five  minutes 
before  the  administration  of  ether  is  begun. 

Technic  of  Operation. — An  incision  is  made  from  the  tip  of  the  mastoid 
process  to  the  sternum  along  the  sternocleidomastoid  muscle.  A 
second  incision  is  made  2  cm.  below  the  edge  of  the  jaw  and  parallel 
with  this  from  the  first  incision  to  a  point  2  cm.  beyond  the  symphysis 
of  the  jaw,  in  order  that  all  of  the  submental  lymph  nodes  may  be 
removed  together  with  the  submaxillary  lymph  nodes  on  the  affected 
side.  If  the  growth  is  located  in  the  middle  portion  of  the  tongue  or  the 
floor  of  the  mouth,  an  incision  must  be  made  along  the  anterior  border 
of  the  sternocleidomastoid  muscle  of  the  opposite  side  as  well.  If  the 
patient  is  in  good  physical  condition,  this  may  be  done  at  the  same 
sitting,  otherwise  the  second  operation  should  be  postponed  until  the 
patient  has  regained  a  sufficient  amount  of  strength  to  make  this  step 
safe,  which  usually  requires  less  than  one  week.  During  this  interval, 
daily  .r-ray  exposures  should  be  made  to  both  sides  of  the  neck.  From 
these  incisions  all  of  the  lymph  nodes  that  may  have  become  invaded 
can  be  removed,  and  the  lingual  artery  and  vein  may  each  be  clamped 
separately  with  two  pairs  of  hemostatic  forceps,  the  former  preferably 
below  and  to  the  inside,  the  latter  to  the  outside  of  the  hypoglossal  muscle. 

After  removing  all  of  the  lymph  nodes  and  ligating  the  vessels,  the 
entire  surface  is  covered  with  gauze  pads  wrung  out  of  hot  water  at 
least  160°  F.  in  order  thoroughly  to  cleanse  the  surface,  and  to  expose 
any  fragment  containing  infected  cells  to  a  temperature  which  is  not 
sufficient  to  destroy  the  normal  tissues,  but  is  supposed  to  be  suffi- 
ciently high  to  disinfect  tissues  containing  a  slight  amount  of  carci- 
noma tissue.  We  have  made  the  dissection  of  the  neck  with  the  fine 
blade  of  an  electric  cautery  a  number  of  times.  This  does  not  seem 
to  interfere  with  the  healing  of  the  wound  and  it  has  seemed  to  protect 
the  patient  against  grafting  of  carcinoma  tissue  with  the  scalpel.  Our 
results  are  not  old  enough,  nor  have  we  made  use  of  the  cautery  in  a 
sufficient  number  of  cases  to  make  it  proper  for  us  to  place  too  much 
emphasis  upon  this  feature  of  the  operation. 


666  MAJOR  OPERATIONS  ON  THE  MOUTH 

The  lymph  nodes  in  and  about  the  submaxillary  salivary  glands  and 
those  located  in  the  angle  formed  by  the  facial  vein  with  the  deep 
jugular  are  most  likely  to  be  infected,  but  it  is  important  to  follow  the 
deep  jugular  vein  throughout  its  course  in  order  that  no  infected  lymph 
nodes  may  be  o^•erlooked. 

After  all  of  the  glands  in  the  entire  field  of  operation  have  been 
removed  and  the  surface  exposed  to  the  hot  pads  for  five  minutes,  the 
wound  along  the  edge  of  the  sternocleidomastoid  muscle  is  carefully 
sutured.  The  space  below  the  jaw  and  chin  is  packed  with  gauze  and 
the  edges  of  the  skin  are  approximated  within  a  distance  of  1  cm.  of 
each  other  by  means  of  interrupted  horsehair  sutures  for  the  purpose 
of  preventing  the  skin  from  curling  up  during  the  time  intervening 
between  this  primary  and  the  secondary  operation  which  is  to  follow 
after  a  period  of  one  to  tw^o  weeks,  according  to  the  condition  of  the 
patient.  By  this  time  the  entire  surface  will  be  so  thoroughly  covered 
with  granulations  that  a  secondary  infection  from  the  secretions  from 
the  mouth  will  be  prevented  following  the  second  operation. 

During  the  interval  between  the  first  and  second  operations  the  neck 
should  be  subjected  to  daily  x-ray  exposures,  and  the  cavity  of  the 
mouth  should  be  disinfected  repeatedly  each  day. 

Technic  of  the  Second  Operation.— It  is  w^ell  to  administer  a  hypo- 
dermic injection  of  I  grain  of  morphin  and  y^Q-  grain  of  atropin  and 
then  to  consume  the  half  hour  following  in  thoroughly  cleansing  and 
disinfecting  the  cavity  of  the  mouth,  then  spraying  the  cavity  for  five 
minutes  with  a  5  per  cent,  solution  of  cocain  and  then  to  administer 
ether  according  to  the  method  described  above. 

After  thoroughly  anesthetizing  the  patient  in  the  horizontal  position, 
a  catheter  of  suitable  size,  just  large  enough  to  fill  the  nostril,  is  intro- 
duced into  the  pharynx  through  each  nostril.  These  catheters  are 
attached  to  a  Y-shaped  glass  tube  whose  third  branch  is  united 
with  a  glass  funnel  by  means  of  a  rubber  tube.  This  arrangement 
will  enable  the  patient  to  breathe  comfortably,  and  in  case  the 
operation  should  be  continued  so  long  that  additional  anesthesia  may 
be  required,  this  can  be  readily  administered  by  placing  a  small  piece 
of  gauze  in  the  funnel  and  saturating  this  with  ether  by  the  drop  method. 

The  wound  beneath  the  jaw  is  then  opened  by  cutting  the  provisional 
sutures,  and  the  cavity  of  the  mouth  is  opened  through  the  space 
formerly  occupied  by  the  gauze  packing.  It  is  best  to  do  this  with  the 
electric  cautery  or  with  the  Paquelin. 

The  malignant  growth  together  with  the  surrounding  tissue  for  a 
distance  of  2  cm.  is  then  removed  with  the  cautery.  There  will  be  very 
little  hemorrhage,  which  can  be  easily  controlled.  It  is  usually  most 
convenient  to  perform  a  part  of  the  operation  through  the  mouth  and 
a  part  through  the  wound  in  the  jaw. 

So  far  as  possible,  the  raw  surfaces  are  covered  by  suturing  and  the 
remaining  surfaces  are  tamponed  with  gauze.  The  space  underneath 
the  jaw  is  again  tamponed  and  the  wound  edges  are  approximated  as 
in  the  primary  operation.     If  possible,  the  cavity  into  the  mouth  is 


SURGICAL  DISEASES  OF  THE  TONSIL  667 

closed  by  means  of  catgut  sutures,  but  if  this  is  not  possible  it  is  packed 
with  gauze  continuous  with  the  packing  in  the  primary  wound.  Iodo- 
form gauze  seems  most  satisfactory  for  this  purpose. 

The  patient  is  placed  in  bed  in  the  sitting  posture,  which  seems  to 
prevent  inspu-ation  pneumonia  as  well  as  hypostatic  pneumonia. 
Liquid  nourishment,  as  concentrated  as  possible  in  composition,  is 
administered  through  a  catheter  inserted  into  the  esophagus  through 
the  nose.  The  mouth  is  sprayed  with  oil  of  eucalj^tus  every  three 
hours. 

After  the  first  week  the  mouth  is  cleansed  and  disinfected  with 
peroxide  of  hydrogen  and  a  saturated  solution  of  chlorate  of  potash 
and  the  spray  with  oil  of  eucalyptus  is  continued. 

After  a  week  the  packing  in  the  submaxillary  space  may  be  removed 
and  the  suture  may  be  tightened  to  produce  an  accurate  coaptation  of 
the  skin.  It  is  well  to  leave  a  small  drain  in  the  lower  angle  of  the 
wound  for  some  days. 

Involvement  of  the  Jaw. — Whatever  operation  may  be  chosen,  it  is 
always  important  to  determine  whether  there  has  been  any  involve- 
ment of  the  jaw. 

In  case  any  portion  of  the  jaw  has  been  attacked  by  the  carcinoma, 
the  entire  surface  involved  should  be  destroyed  by  the  application  of 
the  actual  cautery,  which  should  be  held  in  contact  with  the  bone 
sujfficiently  long  to  insure  the  deep  destruction  of  the  infected  tissue 
over  the  entire  portion  apparently  involved  and  a  distance  of  2  cm. 
beyond  this.  This  can  be  done  most  effectively  by  the  use  of  small 
soldering  irons  heated  to  red  heat  in  a  strong  gas  flame  most  con- 
veniently produced  by  a  cluster  of  Bunsen  burners.  The  sequestrum 
formed  in  this  manner  is  exfoliated  later,  leaving  a  sufiicient  amount  of 
healthy  bone  to  support  the  remainder  of  the  jaw.  This  method  seems 
quite  as  thorough  as  the  complete  removal  of  a  portion  of  the  jaw,  and 
it  leaves  the  patient  in  a  very  much  more  satisfactory  condition,  but 
the  cautery  must  be  very  thoroughly  applied  and  for  a  sufiicient  length 
of  time  to  expose  the  deep  tissues  to  a  high  degree  of  heat.  It  is  impor- 
tant to  use  a  cautery  iron  sufficiently  large  to  carry  a  high  degree  of 
heat  for  a  long  time.  We  have  not  succeeded  in  finding  an  electric 
cautery  sufficiently  heavy  to  do  this.  A  very  large  blade  of  a  Paquelin 
cautery  will  suffice,  but  there  is  no  other  cautery  that  quite  equals  the 
soldering  iron. 


SrEGEEY  OF  THE  XECK. 

By  martin  B.  TINKER,  M.D. 

WRY-NECK  OR  CAPUT  OBSTIPUM  OR  TORTICOLLIS. 

Simple  Wry-neck. — Two  distinct  varieties  of  wry-neck  have  to  be 
considered:  The  ordinary  form  affecting  the  muscles  chiefly  and 
usually  occurring  congenitally  or  among  young  children.  The 
spasmodic  form  in  which  there  are  forcible  cramp-like  contractions 
of  the  muscles,  frequently  attributed  to  nervous  causes. 

Diagnosis. — ^The  appearance  of  the  patient  is  so  characteristic  that 
there  is  little  difficulty  in  diagnosis.  The  head  is  rotated  and  drawn 
dowm  by  the  stemomastoid  muscle  of  the  affected  side.  This  gives 
rise  to  curvature  of  the  cervical  spine  with  its  concavity  toward  the 
affected  side,  and  a  compensatory  curvature  of  the  thoracic  and  lumbar 
vertebrse.  There  is  also  lordosis,  the  curvature  of  the  cervical  vertebrse 
being  markedly  forward.  The  shoulder  of  the  affected  side  is  elevated 
and  in  long  standing  cases  the  bones  of  the  head  and  face  are  deformed 
as  result  of  pressure.  This  deformity  of  the  face  most  frequently 
occurs  with  growing  children.  The  affected  side  of  the  face  is  broader 
and  lower,  the  sound  side  narrower  and  longer,  and  there  is  more  or  less 
atrophy  from  disuse  of  the  soft  parts  as  well  as  the  bony  deformity 
from  pressure.  Probably  the  most  striking  feature  in  the  condi- 
tion is  the  rigidity  of  the  stemomastoid  muscle  which  is  considerably 
shortened  and  runs  in  almost  vertical  direction  from  its  attacliment  at 
the  clavicle  to  the  mastoid  process.  The  rigidity  of  the  muscle  is  diffi- 
cult or  impossible  to  overcome  without  anesthesia  in  many  cases.  The 
sternal  portion  is  usually  more  affected  than  the  clavicular  portion. 
Frequently  many  neighboring  muscles  as  well  as  the  stemomastoid 
are  affected.  Reference  to  Fig.  476  showing  the  characteristic  posi- 
tion of  the  head  and  neck  will  be  more  valuable  than  any  description 
however  extended.  Having  once  seen  the  condition  it  can  hardly  be 
mistaken. 

In  the  differential  diagnosis  we  have  to  consider  a  number  of  con- 
ditions affecting  the  bones  and  soft  parts  which  give  a  somewhat  similar 
position  of  the  head,  although  the  position  is  not  really  characteristic 
of  wry-neck  in  any  of  these  cases.  Tuberculosis  of  the  cervical  spine 
may  cause  somewhat  similar  malposition,  but  it  would  usually  be 
readily  possible  to  locate  the  diseased  vertebra  by  examination  of  the 
cervical  spine.  In  such  cases  there  would  be  decided  pain  and  tender- 
ness on  pressure,  or  on  moving  the  head,  which  would  be  relieved  by 
rest  in  bed.    Wry-neck  is  seldom,  if  ever,  painful. 

(669) 


670 


SURGERY  OF   THE  NECK 


Deep  seated  abscesses  of  the  neck  frequently  caused  by  tuberculosis 
of  the  deep  cervical  glands  may  cause  muscular  contraction  and  may 
result  in  some  cicatricial  contraction,  but  such  deformity  is  not  usually 
extreme  or  characteristic  and  the  history  would  lead  to  a  clear  diag- 
nosis in  most  cases.  Not  infrequently  such  infectious  processes  follow 
t^'phoid  fever,  or  scarlet  fe\er;  less  frequently  measles  or  diphtheria. 
Arthritis  deformans  may  affect  the  cervical  spine,  but  there  is 
a  long  and  characteristic  history  with  involvement  of  other  joints. 
Cicatricial  contractions  of  the  skin  and  subcutaneous  tissue  also  draw 
the  head  to  one  side  and  sometimes  produce  somewhat  similar  deform- 
ity, but  there  is  usually  a  history  of  severe  burn  with  ulceration  and 
resulting  contracture  or  extensive  ulceration  from  carbuncle  or  other 
infection  of  the  neck;  occasionally  from  tuberculosis  or  syphilis.    The 


47ti. — Congenital  wry-neck,     (de  Quervain.) 


painful  stiff  neck  which  sometimes  results  from  sleeping  in  a  draft  in 
rare  cases  may  result  in  more  or  less  permanent  deformity.  Such 
myositis  would  usually  yield  readily  to  hot  compresses,  massage,  and 
suitable  medical  treatment,  and  would  not  be  likely  to  be  mistaken 
for  the  real  permanent  wry-neck.  In  case  syphilitic  or  tuberculous 
involvement  were  suspected,  whether  of  bone,  muscles  or  of  the  skin 
and  superficial  fascia,  the  Wassermann  or  tuberculin  test  might  be  of 
value. 

Treatment.— In  recent  years  a  considerable  number  of  cases  affecting 
nursing  children  have  been  successfully  treated  without  operation  by 
various  methods  of  orthopedic  surgery.  With  these  facts  before  us  it 
wovild  probably  be  unjustifiable  to  operate  in  the  case  of  infants  or 
children  under  two  years  of  age  without  first  giving  orthopedic  measures 
a  thorough  trial.    If  the  case  is  taken  immediately  m  infants  as  soon 


WRY-NECK  OR  CAPUT  OBSTIPUM  OR  TORTICOLLIS        671 

as  the  diagnosis  is  established,  the  results  are  usually  good.  The 
treatment  consists  at  first  in  bringing  the  head  and  neck  into  over- 
corrected  position  and  holding  it  there  a  short  time,  the  manipulation 
being  repeated  a  number  of  times  daily.  Generally  in  such  young 
children  a  very  moderate  amount  of  force  is  necessary.  With  this  is 
given  light  massage,  and  later  on  sometimes  an  extension  apparatus 
is  applied  with  counterextension  on  the  diseased  shoulder.  Various 
forms  of  fixation  dressings  also  may  be  applied,  sometimes  a  plaster-of- 
Paris  bandage  holding  the  head  as  well  as  the  neck  and  shoulders,  or 
in  less  severe  cases  a  molded  paper  or  leather  stock  about  the  neck.  In 
these  very  young  children,  the  little  used  silicate  of  sodium  bandage 
would  answer  every  purpose  and  deserves  to  be  more  generally  used. 
Liquid  glass  for  such  bandages  is  easily  obtained  and  inexpensive.  It  is 
also  very  easy  to  apply,  not  as  sloppy  as  plaster  of  Paris,  and  very  much 
lighter  and  more  comfortable  to  wear. 

Lorenz's  method  of  forcible  replacement  T^iiich  results  in  tearing  the 
muscles  in  most  cases  should  be  mentioned  only  to  be  condemned,  as 
the  tearing  of  bloodvessels  and  nerves  which  has  resulted  in  many 
cases  has  sometimes  been  fatal  or  given  rise  to  permanent  paralysis. 

Operative  Measures. — Snhcutaneous  divmon  of  the  sternomastoid  muscle 
was  formerly  extensively  used  in  the  treatment  of  wry-neck,  but  is 
now  practically  abandoned.  Every  one  who  has  seen,  in  the  open 
operation,  the  extensive  adhesions  usually  present  in  these  cases  and 
the  danger  of  injury  to  the  jugular  vein  which  the  sternomastoid  muscle 
directly  overlies,  would  be  hard  to  convince  of  the  justification  of  this 
method.  In  pre-antiseptic  days  when  the  method  was  introduced  it 
may  have  had  advantages,  but  at  the  present  when  the  cosmetic  affect 
of  a  small  scar  is  the  only  apparent  advantage,  it  would  seem  to  have 
little  to  recommend  it. 

02:)eii  Binsion  of  the  Sternomastoid  Miiscle. — ^Because  of  extensive 
adhesions  usually  present  in  these  cases  and  the  rigidity  of  the  muscles 
of  the  neck,  a  general  anesthetic  is  advisable,  sufficient  to  give 
muscular  relaxation.  The  patient  may  be  placed  with  a  small  sand- 
bag between  the  shoulders  in  order  to  make  the  muscles  more  prominent 
and  the  shoulder  of  the  affected  side  is  less  in  the  way  if  dravvTi  down 
by  an  assistant.  We  believe  that  a  more  liberal  incision  than  is  usually 
recommended  has  decided  advantages,  especially  in  cases  with  extensive 
involvement.  It  is  of  some  advantage  to  place  the  skin  and  muscle 
incision  at  different  levels  so  that  there  is  not  direct  attaclnnent  of  the 
scar  to  the  deeper  parts  of  the  wound.  If  a  low  transverse  incision  is 
used  which  comes  in  line  with  the  normal  folds  and  "s\Tinkles  of  the 
skin,  the  scar  is  usually  insignificant.  The  most  satisfactory  trans- 
verse incision  is  that  employed  by  Robert  Jones,  consisting  of  an  inci- 
sion parallel  with  and  just  superior  to  the  clavicle  and  extending  from 
the  middle  of  the  sternum  to  a  point  just  beyond  the  middle  of  the 
clavicle.  Through  this  incision  the  sternal  as  well  as  the  clavicular 
attachment  of  the  sternocleidomastoid  muscle  can  be  severed,  care 
being  taken  to  cut  all  the  fibers  so  that  when  the  head  is  placed  in  the 


672 


SURGERY  OF  THE  NECK 


overcorrec'ted  position,  the  muscle  has  lost  its  tension  entirely.  The 
results  foUowhig  this  operation  are  most  satisfactory.  In  case  the 
entire  muscle  is  unusually  thick  and  prominent,  it  may  be  preferable 
to  make  an  incision  along  the  anterior  border  of  the  sternomastoid 
muscle  and  to  dissect  this  muscle  free  from  all  of  its  attachments.  The 
muscle  is  then  divided  obliquely  or  split  vertically  and  cut  out  above 
and  below  as  suggested  by  Keen.  The  head  is  placed  in  the  over- 
corrected  position  and  the  distal  ends  of 
the  split  muscle  are  sutured  by  means 
of  a  few  fine  catgut  sutures.  If  these 
methods  of  muscle  plastic  are  used, 
special  care  should  be  taken  to  draw  the 
head  as  far  into  the  overcorrected  position 
as  is  possible  before  suturing  the  muscle. 
It  is  usually  considered  inadvisable  to 
suture  the  muscle  ends  in  the  extreme 
or  long-standing  cases.  The  after-treat- 
ment is  of  a  good  deal  of  importance  in 
many  cases.  As  a  rule  it  is  wiser  to  keep 
the  head  in  the  overcorrected  position  for 
from  one  to  three  months  after  operation 
by  the  use  of  some  retention  bandage. 
If  plaster  of  Paris  is  used,  especial  at- 
tention should  be  given  to  padding  so  as 
to  avoid  pressure  discomforts  and  damage 
to  the  soft  parts.  Exercises  bringing  the 
head  into  the  overcorrected  position  are 
also  of  value.  With  older  patients,  es- 
pecially those  who  are  working  at  a  desk, 
it  is  sometimes  desirable  to  have  a  mirror 
before  them  so  that  they  may  be  reminded 
to  keep  the  head  in  proper  position. 
This  efl'ort  should  also  be  aided  by  re- 
minders from  teachers  and  parents. 

The  operations  above  described  are  all 
that  are  needed  for  cure  in  the  vast 
majority  of  simple  cases  of  wry-neck. 
^'arious  modifications  of  these  methods 
have  been  suggested.  Lange  advises 
division  of  the  muscle  just  below  the 
mastoid  process  and  reports  good  results,  but  it  would  seem  that  there 
would  be  more  disfigurement  without  any  advantage  in  this  method. 
Mikulicz  advised  complete  excision  of  the  sternomastoid  muscle  in 
extreme  cases  and  others  have  modified  this  procedure  to  the  removal 
of  the  lower  segment  of  the  muscle  as  far  as  the  spinal  accessory  nerve. 
The  results  of  simple  division  are  so  satisfactory  that  the  ^Mikulicz 
method  might  perhaps  be  limited  to  the  occasional  recurrences, 
especially  when  of  extreme  form. 


Fig.  477. — Body  and  head  cast 
applied  to  overcorrect  deformity 
after  operation  in  congenital  torti- 
collis.    (Wullstein.) 


WRY-NECK  OR  CAPUT  OBSTIPUM  OR  TORTICOLLIS        673 

Spasmodic  Torticollis  or  Wry-neck.— In  this  condition  the  head  is 
rotated  into  the  wry-neck  position  with  greater  or  less  frequency.  In 
certain  cases  the  rotation  is  combined  with  a  drawing  backward,  some- 
times spoken  of  as  retrocollis. 

Diagnosis. — As  with  simple  wry-neck  there  is  usually  little  difficulty 
in  diagnosis.  The  cramp-like  muscular  contractions,  which  in  some 
cases  are  of  great  severity,  draw  the  head  into  characteristic  position 
which  is  not  seen  in  any  other  disease.  The  contractions  cease  during 
sleep  or  when  the  patient  is  under  general  anesthesia.  In  the  extreme 
cases  it  is  impossible  to  hold  the  head  in  normal  position  by  the  hands 
or  to  retain  it  by  any  ordinary  form  of  fixation  dressing. 

Treatment. — As  the  disease  occurs  most  often  among  patients  with 
decidedly  neurotic  tendencies,  the  nerves  supplying  the  contracted 
muscles  were  formerly  attacked  in  the  surgical  treatment  of  this  con- 
dition. In  later  years  operation  upon  the  muscles  has  come  into  more 
general  favor. 

Nerve  stretching,  usually  limited  to  the  spinal  accessory  nerve,  did 
not  give  permanent  results  and  has  been  practically  abandoned. 

Division  of  the  spinal  accessory  nerve  may  be  tried  in  early  cases  in 
which  the  symptoms  are  not  severe,  and  sometimes  gives  permanent 
results.  For  division  of  this  nerve  a  transverse  incision  may  be  made, 
beginning  just  below  the  mastoid  process  and  extending  downward 
and  forward  toward  the  angle  of  the  jaw.  Beneath  the  skin  the  external 
jugular  vein  and  the  large  auricular  nerve  should  be  avoided.  The 
sternomastoid  muscle  is  retracted  backward,  being  careful  to  avoid  the 
internal  jugular  vein  which  lies  just  beneath  it.  The  spinal  accessory 
nerve  runs  downward  and  backward  into  the  sternomastoid  muscle, 
passing  in  front  of  the  transverse  process  of  the  atlas,  which  is  usually 
so  much  more  prominent  than  the  other  transverse  processes  as  to  be 
readily  distinguished.  The  occipital  artery  usually  crosses  the  nerve, 
running  backward  toward  the  mastoid  process,  and  the  lowest  branch 
of  the  facial  nerve,  which  supplies  the  muscles  of  the  chin  and  outer 
angle  of  the  mouth,  is  sometimes  encountered  and  injured  unless  care 
is  taken.  The  spinal  accessory  nerve  is  covered  by  the  digastric 
muscle  above  and  is  accompanied  by  a  small  arterial  branch  from  the 
external  carotid.  Some  prefer  to  expose  the  nerve  by  incision  along  the 
posterior  border  of  the  sternomastoid  muscle.  As  the  posterior  border 
of  the  muscle  is  dissected,  the  division  of  the  spinal  accessory  nerve 
which  supplies  the  trapezius  muscle  is  usually  readily  exposed,  and  may 
be  used  as  a  guide  to  the  division  which  supplies  the  sternomastoid. 

Division  of  the  upper  three  or  four  cervical  nerves  as  practiced  by  Keen 
and  others  sometimes  gives  a  cure  in  the  more  obstinate  cases.  The 
fact  that  this  method  permanently  paralyzes  the  muscles  involved  and 
has  given  permanent  results  in  less  than  half  the  cases  reported  by 
various  operators  has  led  Kocher  and  others  to  prefer  operation  upon 
the  rotating  muscles  of  the  neck. 

Division  of  the  Rotating  Muscles. — This  is  sometimes  known  as 
Kocher's  operation  for  spasmodic  wry-neck  and  has  given  such  satis- 
voL.  I — 43 


674  SURGERY  OF   THE  NECK 

facton-  results  in  the  hands  of  a  number  of  experienced  surgeons 
(approximately  So  per  cent,  of  cures  or  decided  improvement),  that  it 
may  be  considered  the  operation  of  choice  in  the  more  extreme  and 


CORRUOATOR 


R  NARI8  ANTERIOR.- — -^^ 
NAHIS  POSTERIOR  /r^ 
OR     NARIUM     Minor  -\^E| 


DILATATOR   NARI8   ANTERIOR 
DILATATOR 
COMPRESSOl 

DEPRESSOR  ALAE  NASI. 


Fig.  478. — Superficial  muscles  of  the  neck.     (Gray.) 

obstinate  cases.  Kocher's  description  of  this  operation  is  sufficiently 
concise  and  clear  as  a  guide  for  experienced  surgeons,  but  a  careful 
stud\-  of  the  anatomy  of  the  muscles  of  the  neck,  if  possible  supple- 


WRY-NECK  OR  CAPUT  OBSTIPUM  OR  TORTICOLLIS        675 

mented  by  dissection,  will  prove  of  great  value  to  any  one  planning  to 
undertake  the  operation  and  desiring  the  best  results.  The  anatomy  of 
this  locality  is  so  unfamiliar  to  many,  even  among  active  surgeons, 
that,  without  such  special  study,  it  is  hardly  possible  to  perform  the 
operation  satisfactorily.  Kocher  advises  an  incision  beginning  two 
finger  breadths  below  the  occipital  protuberance  and  extending 
obliquely  domiward  and  forward  to  the  anterior  border  of  the  sterno- 
mastoid  muscle.  The  splenius  capitis  muscle  is  divided  its  entire 
breadth,  being  careful  not  to  go  too  near  its  insertion  in  order  to  avoid 


Fig.  479. — Muscles  of  the  neck.     Lateral  view.     (Graj^) 


the  minor  occipital  nerve  and  the  occipital  artery.  Laterally  from  the 
splenius  capitis  the  longissimus  capitis  (better  kno's^Ti  to  many  as  the 
trachelomastoid)  is  divided  just  below  its  insertion  into  the  mastoid 
process,  and  lying  next  this  muscle  the  attachments  of  the  splenius 
cervicis  to  the  transverse  processes  of  the  first  and  second  cervical 
vertebrse  are  divided.  Next  the  lateral  edge  of  the  thick  semispinalis 
capitis  (complexus)  is  dra-^ii  toward  the  median  line  with  retractors 
and  divided,  for  under  this  muscle  lies  one  of  the  most  important  of  the 
rotating  muscles,  the  obliquus  capitis  inferior.  This  muscle  is  attached 
to  two  spmous  processes  and  extends  to  be  mserted  into  the  transverse 


676 


SURGERY  OF  THE  NECK 


process  of  the  atlas.  Kocher  emphasizes  the  thorough  division  of  this 
muscle,  avoiding  at  the  same  time  injury  of  the  major  occipital,  a 
sensory  nerve  which  winds  around  the  lateral  border  of  the  muscle. 
This  operation  is  complicated  and  difficult,  but  with  careful  study  it 
can  be  correctly  carried  out  by  any  man  thoroughly  familiar  with 
surgery,  and  it  has  given  most  excellent  results  in  the  hands  of  a 
number  of  experienced  surgeons.  In  case  the  extensor  muscles  are  also 
involved  (retrocollis),  still  more  extensive  operation  is  necessary.    Not 


Fig.  480. — The  anterior  vertebral  muscles  of  the  neck.     (Gray.) 


only  the  trapezius  and  complexus  and  also  the  attachments  of  the 
semispinalis  cervicis  to  the  spinous  processes  of  the  two  cervical 
vertebrae,  but  also  the  smaller  muscles  of  the  neck,  the  rectus  capitis 
major  and  minor,  and  the  superior  oblique  must  be  divided,  because  of 
their  connection  with  the  skin  of  the  back  of  the  neck.  In  certain 
cases  both  sides  must  be  operated  upon.  In  order  to  avoid  disfiguring 
sinking  in  of  the  scar  at  the  back  of  the  neck,  Kocher  suggests  muscle 
transplantation,  attaching  the  stump  of  the  longissimus  capitis  to  the 
proximal  stump  of  the  trapezius.     In  order  to  do  this  both  stumps 


CONGENITAL  FISTULA  OF  THE  NECK 


Q11 


must  be  left  long.  A  plaster-of-Paris  dressing  is  then  applied.  There 
has  been  such  a  large  percentage  of  relapses  or  complete  failures  from 
poorly  planned,  indiscriminate  cutting  of  the  muscles  of  the  neck  for 
the  relief  of  spasmodic  wry-neck,  that  Kocher's  admirable  method 
deserves  careful  attention. 

CONGENITAL  FISTULA  OF  THE  NECK. 

Median  and  lateral  fistulse  are  seen  which  arise  from  imperfect 
embryonic  development.  The  lateral  fistulse  arise  from  imperfect 
closure  of  the  second  gill  slit  or  branchial  cleft,  as  is  the  case  with  certain 
cysts  in  this  locality,  while  median  fistulge  are  generally  considered  to 
have  no  connection  with  the  branchial  cleft,  but  to  arise,  as  do  the 
cysts,  from  abnormality  in  the  development  of  the  thyreoglossal  duct. 
The  origin  of  these  fistulse  is  of  aid  in  diagnosis  because  of  their  char- 
acteristic location.  As  a  rule  the  lateral  fistulse  are  originally  incom- 
plete internally  and  perforation  occurs  secondarily  later  in  life. 


Fig.  481. — Congenital  median  fistula  of  the  neck,     (de  Quervain.) 

While  arising  from  imperfect  embryologic  development  the  median 
fistulcB  are  usually  not  congenital  while  the  lateral  fistulse  are  very  com- 
monly so.  With  the  latter  there  is  as  a  rule  a  small  punctiform  opening 
with  a  moist  surface  between  the  hyoid  bone  and  the  thyroid  cartilage. 
It  is  frequently  difficult  to  pass  a  probe  very  far  along  the  fistulous 
tract  because  it  usually  passes  directly  over  the  hyoid  bone  and  in 
some  cases  passes  through  it,  and  there  also  may  be  narrowed  places 
which  will  not  admit  a  probe.  The  injection  of  methylene  blue  solu- 
tion, or  better  hot  permanganate  potassium  saturated  solution,  into 
the  tract  is  an  aid  in  following  it  at  the  time  of  operation,  or  its  course 
might  be  located  more  accurately  by  the  use  of  bismuth  paste  and 
ic-ray.    This  method  is  especially  valuable,  because  these  fistulse  are 


678  SURGERY  OF  THE  NECK 

frequently  very  irregular  in  their  structure,  and  often  have  a  number 
of  branches.  This  irregularity  is  frequently  increased  as  a  result  of 
unsuccessful  operations.  After  determining  the  form  and  extent  of  the 
fistula  by  this  method,  it  is  frequently  wise  to  fill  the  cavity  with  hard 
paraffin  at  a  melthig-point  of  120°,  which  has  been  liquefied  by  heating, 
and  which  should  be  forced  into  the  fistula  so  that  it  will  fill  all  the 
portions  of  the  cavity.  It  will  immediately  harden  in  this  cavity  and 
will  indicate  the  form  and  extent  of  the  cavity  so  that  the  entire 
lining  of  the  fistula  can  be  excised  intact.  In  case  the  fistula  have 
become  infected  the  differential  diagnosis  between  a  congenital  fistulne 
and  a  sinus  leading  to  a  broken-down  gland  might  offer  some  difficulty. 
If  the  lining  membrane  were  excised,  however,  the  true  character  of  the 
condition  would  be  recognized  microscopically  by  finding  character- 
istic ciliated  epitheliiun  lining  the  fistulous  tract. 

With  the  lateral  fistulce  of  the  neck  the  opening  is  located  fre- 
quently along  the  side  of  the  neck  between  the  median  line  and 
the  anterior  border  of  the  sternomastoid  muscle.  It  is  said  to 
occur  most  frequently  just  above  the  sternoclavicular  articula- 
tion, but  in  many  cases  the  opening  is  located  higher  in  the  neck 
at  the  level  of  the  cricoid  cartilage  or  even  as  high  as  the  thyroid 
cartilage.  The  course  of  the  fistula  from  without  inward  is  through 
the  subcutaneous  tissues,  the  platysma  muscle,  the  superficial 
fascia,  then  parallel  to  the  sternomastoid  muscle  upon  the  fascia 
overlying  the  sternohyoid  muscle  upward  toward  the  hyoid  bone.  It 
usually  passes  over  the  origin  of  the  internal  carotid,  between  the 
internal  and  external  carotid  arteries,  underneath  the  digastric  muscle, 
and  ends  in  the  lateral  wall  of  the  pharjiix.  In  many  instances  it  is 
closely  adherent  to  the  sheath  of  the  great  vessels  and  it  crosses  the 
stylophar^iigeus  muscle  as  it  enters  the  pharynx.  The  h^'poglossal 
nerve  and  the  glossophar^^lgeal  nerve  usually  lie  under  it.  Either  the 
outer  or  inner  portion  of  this  tract  may  persist,  forming  an  incomplete 
internal  or  incomplete  external  fistula,  or  the  entire  tract  may  remain 
patulous.  The  right  side  of  the  neck  is  said  to  be  more  commonly 
affected,  and  contrary  to  the  case  of  median  fistula  it  is  usually  present 
at  birth.  The  secretion  is  usually  thin  mucus  which  may  become 
turbid,  containing  pus  if  the  fistulous  tract  is  infected.  The  quantity 
varies  from  a  few  drops  to  a  sufficient  amount  to  be  very  troublesome, 
causing  eczema  of  the  skin  surrounding  the  opening.  With  the  incom- 
plete internal  fistula  particles  of  food  may  be  retained  and  give  the 
impression  of  a  diverticulum  of  the  esophagus.  The  differential 
diagnosis  from  fistula  leading  to  broken  down  suppurating  Ij'mphatic 
glands  or  other  deep  infection  of  the  neck  is  usually  easy.  Removal  of 
a  portion  of  the  fistulous  tract  and  microscopic  examination  give  a 
positive  diagnosis  as  the  fistulous  tract  is  lined  with  cylindrical  epithe- 
lium in  that  portion  deeply  seated,  while  the  superficial  part  of  the 
tract  is  lined  with  pavement  epithelium. 

Treatment." — The  only  certain  method  of  cure  is  careful  excision  of  the 
entire  tract.  With  the  median  fistulse  it  is  usually  possible  to  accomplish 


INJURIES  OF  THE  NECK  679 

this  under  local  anesthesia.  As  the  fistulous  tract  sometimes  extends 
over  the  hyoid  bone  or  even  passes  through  it,  complete  removal  is 
sometimes  difficult,  and  in  some  cases  portions  of  the  hyoid  bone  have 
been  resected.  It  might  be  possible  in  certain  instances  to  obliterate  a 
portion  of  the  fistula  by  injection  of  some  irritating  fluid.  The  injec- 
tion of  zinc  chloride  solution  and  pure  carbolic  acid  or  strong  solutions 
of  silver  nitrate  have  been  tried  in  certain  cases,  but  are  not  usually 
successful.  The  tract  is  often  so  tortuous  and  so  narrow  in  places  that 
probably  the  caustic  solution  does  not  reach  every  portion  of  it.  If  the 
entire  fistulous  tract  were  open  there  would  be  considerable  danger  of 
such  irritating  poisonous  fluids  entering  the  pharjnix.  Scraping  out 
the  fistulous  tracts  with  a  sharp  curette  is  not  a  successful  means  of  cure. 
With  the  lateral  fistulse  excision  is  very  much  more  difficult  because  of 
deep  location  along  important  anatomical  structures.  The  injection 
of  bismuth  paste  or  of  methylene  blue  solution,  or  hot  saturated 
solution  of  permanganate  of  potassium,  might  facilitate  the  removal 
of  these  deeper  fistulse,  and  a  liberal  skin  incision  and  general 
anesthesia  would  be  necessary  for  successful  removal  of  the  deep 
fistulee .  Ponacker  simplified  the  removal  of  complete  fistula  by  excising 
the  external  portion  as  far  as  the  digastric  muscle.  He  then  passed  a 
loop  of  silk  from  the  internal  opening  using  a  probe  as  a  guide  and 
by  this  means  was  able  to  invert  the  inner  portion  of  the  tract  and 
excise  it. 

INJURIES  OF  THE  NECK. 

Bums. — Extensive  burns  are  of  special  importance  in  this  locality, 
not  only  because  of  immediate  danger  to  life  of  inhaling  fiames  but 
because  of  the  tendency  to  scar  tissue  contraction,  which  may  draw  the 
head  into  malposition,  resembling  true  ^Ty-neck  or  which  may  other- 
wise greatly  hamper  and  disfigure  the  patient. 

Treatment. — ^The  superficial  burns  of  the  neck  may  be  treated  in  many 
different  ways  with  satisfactory  results.  A  thick  covering  of  sterile  vase- 
Ime  which  protects  from  the  air,  relieves  burning  and  pain  and  the  use  of 
antiseptics  is  unnecessary  if  the  deeper  true  skin  is  uninjured.  Deeper 
burns  should  be  treated  like  wounds  of  any  other  part  of  the  body  with 
as  thorough  antiseptic  precautions  as  would  be  used  with  any  wound. 
The  dense  scar  tissue  which  causes  serious  contractures  is  usually  the 
result  of  prolonged  suppuration  and  this  can  be  avoided  in  most  cases 
by  a  thorough  preliminary  cleaning  up  under  general  anesthesia  and 
careful  after-attention.  As  soon  as  granulations  have  formed,  skin  graft- 
ing may  be  used  in  the  case  of  more  extensive  burns.  Part-thicknpss 
grafts  are  satisfactory  if  these  cases  are  taken  early,  but  in  the  extensive 
contractures  which  follow  burns  pedicle  flaps  or  full-thickness  grafts  are 
usually  necessary.  Frequently  several  flaps  can  be  turned  from  the 
upper  part  of  the  chest  to  cover  such  a  surface  on  the  neck,  or  a  pedicle 
flap  may  sometimes  be  taken  from  the  forearm.  In  case  muscles 
have  been  badly  matted  together  in  scar  tissue  it  may  be  necessary  to 


680  SURGERY  OF  THE  NECK 

dissect  them  out  and  practice  some  of  the  methods  of  muscle  lengthen- 
ing.   Transplantation  of  fat  may  be  used  to  prevent  readhesion. 

Injuries  of  the  Deeper  Parts  of  the  Neck. — Injuries  of  the  great 
bloodvessels  and  nerves  of  the  neck  are  of  relatively  infrequent  occur- 
rence, in  times  of  peace  aside  from  accidental  or  intentional  injury 
during  extensive  operations.  The  experiences  of  the  great  war  have 
given  a  new  significance  to  such  injuries.  Injury  of  the  large  arteries 
results  fatally  within  a  very  few  minutes,  at  the  most,  unless  intelligent 
first  aid  is  at  hand.  Instruction  in  first  aid,  which  is  now-much  more 
generally  given  than  formerly,  will  doubtless  make  it  possible  to  save 
the  lives  of  many.  If  the  hemorrhage  is  from  one  of  the  great  vessels 
of  the  upper  part  of  the  neck  it  may  be  possible  to  arrest  it  by  pres- 
sure over  the  common  carotid  agains,t  the  transverse  processes  of  the 
vertebra.  If  the  subclavian  is  injured  pressure  of  the  artery  against 
the  first  rib  may  be  possible.  Pressure  with  the  finger  immediately 
over  the  bleeding  point  is  perhaps  more  generally  useful  than  anything 
else  while  efforts  are  being  made  to  secure  the  vessel  permanently. 
A  double  ligature  of  the  artery  involved  or  arterial  suture  are  of  course 
the  only  reliable  means  of  permanent  arrest  of  hemorrhage.  The 
ligation  of  the  various  arteries  will  be  taken  up  in  detail  elsewhere. 

Injuries  of  the  larger  veins  may  give  serious  bleeding  and  this  is 
particularly  true  of  the  neck  for  the  reason  that  the  veins  do  not  have 
valves.  In  many  cases  it  is  possible  to  control  venous  hemorrhage  by 
a  firmly  placed  tampon  while  preparation  is  made  to  secure  the  vessel 
or  bleeding  point  permanently.  The  entrance  of  air  into  the  larger 
veins  of  the  neck  causing  air  embolus  is  also  a  possible  source  of  trouble 
in  injuries  of  the  veins.  Recent  studies  show  that  air  may  be  injected 
into  the  larger  veins  without  producing  serious  results  and  it  is  quite 
possible  that  the  dangers  of  air  embolus  have  been  considerably 
exaggerated.  It  seems  that  fatal  results  occur  only  when  the  vein  is 
widely  open  during  inspiration  so  that  a  large  amount  of  air  is  inspired 
quite  suddenly,  sufficient  in  quantity  to  cause  an  acute  dilatation  of  the 
heart  or  the  formation  of  foam  or  the  production  of  a  thrombus. 
Filling  the  wound  with  saline  solution  or  packing  in  gauze  firmly  would 
prevent  the  aspiration  of  air  into  the  larger  veins  in  case  of  injury 
during  operation.  Leaving  clamps  in  the  wound  on  the  larger  veins  for 
considerable  time  is  a  method  which  is  occasionally  employed,  but 
which  we  have  not  used. 

Injuries  of  the  large  nerve  trunks  of  the  neck  are  also  of  infrequent 
occurrence  except  in  war.  The  monograph  of  Mitchell,  Morehouse 
and  Keen  on  nerve  injuries  occurring  during  the  Civil  War  is  still  one 
of  our  most  valuable  sources  of  information  in  these  cases  and  numerous 
monographs  have  appeared  during  the  World  W^ar,  that  of  Tinel 
specially  careful  and  complete.  A  complete  report  of  the  results 
of  surgery  in  the  World  War  wall  not  be  available  soon,  not  alone 
because  two  or  three  years  must  elapse  before  one  can  be  positive  of 
results  in  nerve  surgery  but  also  because  of  the  vast  material  to  be 
studied. 


INJURIES  OF  THE  NECK 


681 


Brachial  Plexus  Injuries.— The  brachial  plexus  is  sometimes  injured 
not  only  by  gunshot  or  stab  wounds  but  frequently  by  some  force 
separating  the  head  from  the  shoulder.  The  plexus,  formed  of  the 
fifth,  sixth,  seventh  and  eighth  cervical  nerve  roots  and  the  first  dorsal 
is  of  triangular  form  with  the  base  at  the  vertebral  roots  and  all  trunks 
converging  to  the  apex  at  the  axilla.  Hence  lesions  at  the  axillary 
apex  and  just  above  the  clavicle  usually  involve  several  trunks  and  the 
great  vessels.  That  neither  fatal  outcome  or  extensive  injury  may 
result  was  seen  by  three  gunshot  injuries  through  this  dangerous  area 


Fig.  482. — Gunshot  wound  just  above  the  clavicle  at  the  base  of  the  neck,  in  the 
neighborhood  of  the  important  nerve  trunks  of  the  brachial  plexus  and  the  great  vessels. 
Dark  area  shows  anesthesia.  Flattening  of  shoulder  from  deltoid  paralysis.  This  case 
is  one  of  three  gunshot  injuries  at  the  root  of  the  neck,  observed  at  U.  S.  General  Hos- 
pital No.  26,  Ft.  Des  Moines,  la.,  in  wliich  patient  survived  with  surprisingly  little 
disability  after  injury  in  this  important  area. 


treated  at  Ft.  Des  Moines.  (See  Fig.  482.)  The  higher  spinal  nerve 
roots  take  an  oblique  course,  the  lower  ones  are  almost  horizontal. 
This  arrangement  of  the  plexus,  (diagrammatically  illustrated  by  Taylor, 
see  Figs.  483-484)  puts  the  strain  of  forcible  separation  of  the  head 
from  the  shoulder,  first  upon  the  upper  cervical  roots  then  upon  the 
next  lower  roots,  in  their  order  from  above  downward.  Gunshot  and 
stab  wounds  occasionally  injure  the  roots  near  the  intervertebral 
foramina  before  they  unite  to  form  the  primary  nerve  trunks  of  the 
plexus.    A  case  of  this  kind  was  observed  among  the  war  injuries  at 


682 


SURGERY  OF  THE  NECK 


U.  S.  General  Hospital  No.  20,  in  which  only  the  rhomboid  muscles 
were  involved.  The  primary  trunks  are  also  occasionally  affected. 
The  symptoms  resulting  are  dependent,  of  course,  upon  the  trunk 
involved.  The  fifth  and  sixth  cervical  root  form  the  upper  trunk; 
the  eighth  cervical  and  first  dorsal,  the  lower  trunk;  and  the  seventh 
cervical  the  middle  trunk.  Each  of  these  divides  into  an  anterior 
and  posterior  branch.  The  anterior  branches  of  the  upper  and  middle 
trunk  form  the  upper  secondary  trunk  of  the  plexus,  which  gives  off  the 
musculocutaneous  nerve  and  the  external  root  of  the  median.  The 
anterior  branch  of  the  lower  trunk  constitutes  the  inner  cord  of  the 


EX.  DIG.  COMMUNIS 


EX.DieiTI     QUINTI    PROPRIUS 


TRICEPS  (partial   PARALYSIs) 


EX.  CARPI      RAD.  LONG. 
ANCONEUS 
X.  CARPI     RAD.  BREVIS 

ABDUCTOR    POLLICIS   LON6US 
EX.  POLLICIS    BREVIS 


Fig.  483. — Posterior  view.    Lower  radicular  group;  eighth  cer\'ical  root  and  first  dorsal. 


pleXus,  gives  off  the  ulnar  and  the  internal  root  of  the  median  as  well 
as  the  internal  cutaneous  and  lesser  internal  cutaneous  nerves.  The 
three  posterior  branches  form  the  posterior  cord  which  gives  off  the 
circumflex  and  afterward  forms  the  musculospiral  nerve.  The  supra- 
clavicular area  is  essentially  that  of  the  primary  nerve  trunks  of 
the  plexus  and  their  branches  of  division.  The  diagnosis  of  certain 
injuries  is  fairly  easy  because  of  the  definite  distribution  of  the  nerves. 
Paralysis  of  the  rhomboid  muscles  indicates  injury  of  the  fifth  cervical 
nerve  root  as  the  nerve  to  these  muscles  comes  directlv.  from  it.     The 


INJURIES  OF  THE  NECK 


683 


nerve  to  the  serratus  magnus  originates  from  the  fifth  and  sixth  cervical 
roots.  The  suprascapular  nerve  comes  from  the  upper  primary  cord 
of  the  plexus  and  is  almost  invariably  affected  in  injuries  causing 
forcible  separation  of  the  head  from  the  shoulder.  The  upper  branch 
to  the  subscapular  muscle  also  comes  from  the  upper  cord  of  the  plexus 
just  after  it  divides  into  the  anterior  and  posterior  branches  which 
form  the  secondary  cords  of  the  plexus.  All  the  cervical  roots  send 
communicating  branches  to  the  cervical  sympathetic  but  the  branch 
from  the  first  dorsal  is  especially  important  as  it  carries  to  the  lower 


BRACHIALIS   ANTICUS 


BRACHIORADIALIS 


pectoralis   major 
(clavicular  portion) 


SERRATUS  MAGNUS 


Fig.  484. — ^Anterior  view.     Upper  radicular  group,  fifth  and  sixth  cervicals. 


cervical  ganglion   of  the   sympathetic    the    ciliospinal   fibers  which 
innervate  the  pupil  of  the  eye. 

In  injuries  of  the  nerve  roots  and  primary  cords  of  the  plexus  we 
have  the  so-called  radicular  syndromes.  A  great  number  of  muscles 
are  supplied  by  two  and  often  three  different  roots,  consequently 
partial  paralysis  of  these  muscles  results  and  there  is  tendency  to 
spontaneous  improvement.  There  are  also  extensive  sensory  sub- 
stitutions between  nerve  roots  so  that  the  sensory  symptoms  are  less 
definite  than  the  anesthesia  from  lesions  of  the  peripheral  nerves. 


684 


SURGERY  OF  THE  NECK 


Three  partial  radicular  syndromes  are  usually  described:  First, 
of  the  fifth  and  sixth  cervical  roots,  the  upper  radicular  group  forming 
the  upper  primary  cord  of  the  plexus.  This  is  conmionly  spoken  of  as 
the  Erb-Duchenne  syndrome.  The  muscles  affected  are  the  deltoid 
(circumflex  nerve);  biceps  and  brachialis  anticus  (musculocutaneous 
nerve);  supinator  longus  (musculospiral  nerve).  There  is,  of  course, 
complete  loss  of  flexion  of  the  elbow  since  biceps,  brachialis  anticus 
and  supinator  longus  are  all  gone.  There  is  also  paralysis  of  the 
clavicular  head  of  the  pectoralis  major,  the  supra-  and  infraspinatus 
and  the  subscapularis;  and  the  teres  major  whose  nerve  supply  comes 


RHOMBOIDEUS 


LEVATOR    AN6UL1    SCAPULI 
-SUPRASPINATUS 
•INFRASPINATUS 


SUBSCAPULARIS 
SERRATUS   MASNUS 


Fig.  485. — Posterior  \'iew;  upper  radicular  group,  fifth  and  sixth  cervicals. 

from  the  upper  primary  cord  or  its  branches.  If  the  lesion  is  near  the 
spinal  roots  there  may  be  paralysis  of  the  rhomboids,  the  serratus 
magnus  and  the  levator  anguli  scapulae.  The  upper  radicular  groups 
also  partially  supplies  the  coracobrachialis,  triceps,  the  radial  exten- 
sors and  supinator  brevis,  pronator  radii  teres  and  the  flexor  carpi 
radialis  together  with  the  extensor  and  flexor  muscles  of  the  thumb. 
These  muscles  are  usually  slightly  weakened,  at  least  temporarily. 
There  is  hypesthesia  instead  of  anesthesia  as  with  peripheral  nerve 
lesions  and  is  indicated  in  Fig.  486,  a  photograph  of  actual  injury 
studied  at  U.  S.  General  Hospital  No.  26. 


INJURIES  OF  THE  NECK. 


685 


The  middle  radicular  syndrome  is  characterized  by  paralysis  of  the 
muscles  supplied  by  the  musculospiral  nerve,  excepting  the  supinator 
longus.  This  root  takes  its  origin  from  the  seventh  cervical  and  forms 
the  middle  primary  cord  of  the  plexus.  The  triceps  is  weakened  but 
not  paralyzed,  being  partially  supplied  by  the  sixth  cervical.  The 
clinical  picture  is  almost  exactly  like  that  of  lead  palsy.  There  is 
slight  hypesthesia  over  the  dorsal  surface  of  the  forearm  and  outer 
part  of  the  dorsum  of  the  hand,  as  the  sensory  supply  of  the  seventh 
cervical  is  very  limited. 

The  lower  radicular  syndrome  (Aran-Duchenne)  caused  by  injury 
of  the  eighth  cervical  and  first  dorsal  roots  which  form  the  primary 
lower  cord  of  the  plexus,  is  characterized  by  paralysis  of  the  flexors  of 
fingers,  the  flexor  carpi  ulnaris,  the  interossei,  the  thenar  and  hypoth- 


FiG.  486. — ^Area  of  hypesthesia  characteristic  of  injury  of  fifth  and  sixth  cervical 
roots  or  upper  primary  cord  of  brachial  plexus.  Gunshot  wound  treated  at  U.  S.  General 
Hospital  No.  26,  Ft.  Des  Moines,  la. 

enar  eminences.  Those  muscles  which  are  supplied  by  the  median  are 
innervated  from  the  eighth  cervical  while  the  ulnar  takes  its  origin 
mainly  from  the  first  dorsal.  Hence  injury  gives  nearly  the  appearance 
of  combined  paralysis  of  the  median  and  ulnar  nerves,  with  the  flattened 
hand,  if  complete  division,  and  griff e,  if  only  nerve  irritation.  The 
pronator  radii  teres  and  flexor  carpi  radialis  receive  from  the  outer 
root  of  the  median,  fibers  from  the  sixth  and  even  the  seventh  cervical 
and  are  not  usually  affected  in  lower  root  lesions.  The  sensory  area 
is  a  band  of  hypesthesia  along  the  inner  side  of  the  arm.  Sometimes 
with  injury  of  the  lower  roots  the  oculopupillary  syndrome  of  ]\Ime. 
Dejerine-Ivlumpke  is  present,  consisting  of  myosis,  enophthalmos  and 
narrowing  of  the  palpebral  fissure. 


686 


SURGERY  OF   THE  NECK 


The  syndrome  caused  by  injury  of  the  secondary  cords  of  the  plexus 
resemble  peripheral  injuries.  The  upper  secondary  cord  corresponds 
to  paralysis  of  the  musculocutaneous  and  outer  head  of  the  median. 
The  posterior  secondary  trunk  corresponds  to  musculospiral  and  cir- 
cumflex paralysis;  the  lower  secondary  trunk,  to  paralysis  of  the 
inner  head  of  the  median  and  ulnar  with  lesion  of  the  internal  cutaneous 
and  lesser  internal  cutaneous. 


Fig.  487. — ^Circumflex  nerve  paraly.si.s 
from  gunshot  wound.  Area  of  anesthesia 
in  paralysis  of  fifth  cer\-ical  root.  Degree 
of  abduction  of  the  arm  from  tilting  the 
scapula.     Scar  on  back  from  gas  burn. 


Tig.  488. — Abduction  of  the  arm  by 
action  of  deltoid.  Movement  of  scapula 
limited  by  paralysis  of  spinal  accessory 
nerve.  Note  difference  between  attitude 
and  fulness  of  the  shoulder  in  this  injury 
and  that  in  which  the  circumflex  nerve  is 
involved. 


The  nerve  trunk  "injured  can  be  reasonably  accurately  located  by 
the  paralysis  or  sensory  disturbances  which  follow.  Injuries  of  the 
cervical  sympathetic  when  irritation  only  is  present  may  produce 
paleness  and  coolness  of  the  skin,  protusion  of  the  eyeball,  dilatation 
of  the  pupil  on  the  affected  side.  When  paralysis  results  permanent 
flushing  and  increased  surface  temperature  of  the  face  results.  Dis- 
turbance in  the  heart's  action  has  not  been  reported.  Injury  of  the 
pneumogastric  causes  difficulty  in  breathing  and  sometimes  sudden 
arrest  of  the  heart's  action.  This  is  far  less  likely  to  occur  if  the  nerve 
is  divided  than  if  it  is  crushed  or  pulled  upon.  Paralysis  of  the  recur- 
rent laryngeal  nerve  with  hoarseness  may  result  from  injury  of  the 


INJURIES  OF  THE  XECK 


687 


pneiimogastric  or  from  pressure  on  it.  Injury  of  the  recurrent  nerve 
itself  is  unlikely  except  in  operations  upon  the  thyroid  or  possibly 
some  extensive  dissections  for  the  removal  of  malignant  gro-tti:h.  A 
few  injuries  of  the  phrenic  nerve  have  caused  paralysis  of  the  diaphragm 
and  lower  part  of  the  thorax.  AMiile  the  s^Tnptoms  have  been  serious 
in  some  cases,  no  fatalities  have  been  reported  and  no  attempt  at  treat- 
ment has  been  made.    Nerve  suture  as  early  as  possible  has  given  very 


Fig.  489. — Same  case  as  Fig.  488  sho-ning 
movement  of  arm  possible  when  the  scapula 
is  fixed  on  the  chest  wall  by  the  hand  of  an 
assistant. 


Fig.  490.  —  Area  of  hjiDesthesia 
characteristic  of  eighth  cervical  and 
first  dorsal  root  involvement,  or  the 
lower  primarj-  cord  of  the  brachial 
plexus.  Gunshot  wound  obser\'ed  at 
U.  S.  General  Hospital  Xo.  26,  Ft. 
Des  Moines,  la. 


satisfactory  results  when  the  nerves  of  the  brachial  plexus  or  spmal 
accessor}'  have  been  divided .  Interference  with  the  vagus  is  too  danger- 
ous to  make  any  attempt  at  suture  seem  advisable,  indeed  when 
difficult  respu-ation  or  sudden  stoppage  of  the  heart  has  followed 
crushmg  injury,  immediate  division  possibly  after  cocainization  has 
been  advised.  The  results  of  injury  of  the  s}-mpathetic  have  not  proved 
serious  enough  to  warrant  any  special  treatment. 


688 


SURGERY  OF  THE  NECK 


Brachial  Birth  Palsy. — Brachial  birth  palsy  is  an  injury  of  sufficient 
frequency  to  deserve  special  mention.  A  summary  of  the  essential 
features  of  this  interesting  condition  by  Alfred  Taylor^  puts  the  situa- 
tion as  concisely  as  it  can  be  stated  by  one  who  has  probably  had  the 
greatest  experience  in  the  surgical  treatment  of  this  condition. 

The  essential  etiologic  factor  consists  in  the  forcible  separation  of 
the  head  and  neck  from  the  shoulder  on  the  side  of  the  lesion.  The  deep 
cervical  fascia,  the  nerve  sheaths,  the  nerves  and  small  accompany- 
ing vessels  are  torn.     After  a  time  the  resulting  blood-clot  and  torn 

structures  form  a  dense  cicatrix 
which  prevents  nerve  regener- 
ation. As  a  rule  the  injury  in- 
\olves  the  roots  in  order  from 
a})ove  downward,  and  may  vary 
in  extent  from  a  slight  injury  of 
the  upper  root  to  a  complete 
rupture  of  the  entire  plexus.  In 
some  cases  roots  are  torn  from 
the  cord  itself.  Secondary  patho- 
logic changes  occur  in  the  mus- 
cles, ligaments,  and  joint-ends  of 
the  bones.  The  paralyzed  muscles 
are  grouped  according  to  the  roots 
injured.  The  characteristic  atti- 
tude is  marked  inward  rotation 
of  the  whole  extremity,  which  is 
accented  by  the  pronation  of  the 
forearm  and  hand.  There  is  al- 
ways some  posterior  displacement 
of  the  upper  end  of  the  humerus 
as  compared  with  the  normal  side, 
and  in  a  few  cases  complete  pos- 
terior dislocation  of  the  shoulder. 
Sensory  distm-bances  are  slight 
and  usually  soon  disappear.  In- 
terference with  growth  is  always 
present  and  is  most  marked  about 
the  shoulder  girdle.  Deformity  usually  increases  with  age.  A  cicatrix 
can  easily  be  felt  in  the  region  of  the  damaged  nerves,  and  is  usually 
tender  even  after  years. 

Prognosis  is  bad.  There  is  nearly  always  some  degree  of  deformity 
and  paralysis  which  persists. 

Operation  as  early  as  the  general  condition  will  permit  (three  to 
twelve  weeks)  gives  the  best  prospect  for  a  useful  arm.  In  the  few 
cases  in  which  complete  spontaneous  recovery  will  occur  the  paralysis 
is  usually  not  extensive,  improvement  starts  early,  continues  rapidly, 


Fig.  491.  —  Before  operation.  Ordinary 
attitude  of  right  arm;  inward  rotation  of 
arm;  pronation  of  forearm;  flexion  at  elbow; 
marked  flexion  at  wrist.    (Taylor.) 


1  Am.  Jour,  of  the  Med.  Sc,  Dec,  191.3,  No.  6,  cxlvi,  p.  836. 


INJURIES  OF  THE  NECK  689 

and  operation  is  contra- indicated.  In  debatable  cases  operation 
amounts  to  early  exploration,  with  repair  of  such  damage  as  may  be 
found.  There  is  exceedingly  little  danger  in  the  operation,  which 
amounts  only  to  an  incision  through  the  skin  and  fat  at  the  base  of  the 
neck. 

Before  operation  the  extremity  should  be  held  in  a  sling  to  take  its 
weight  off  the  damaged  nerv^es  and  paralyzed  muscles. 

In  cases  where  roots  have  been  torn  from  the  cord  they  must  be 
laterally  implanted  into  the  neighboring  roots,  or  if  the  neighboring 
roots  have  been  damaged  enough  to  require  resection  all  of  the  distal 
nerve  trunks  may  be  sutured  in  a  bunch  to  the  proximal  roots  still 
attached  to  the  cord. 

_  After  operation  the  head  and  shoulder  must  be  held  in  approxima- 
tion for  weeks  by  a  steel  brace  fitted  before  operation. 

As  Taylor  states,  the  criterion  of  treatment  is  its  result.  In  his 
series  of  200  cases  reported  at  the  American  College  of  Surgeons, 
October  1919,  70  were  operated  upon  and  in  130  cases,  operation  was 
refused  by  the  parents  or  physician  in  charge.  Of  this  number  there 
are  only  2,  or  1  per  cent.,  of  spontaneous  recovery.  Of  the  70  operative 
cases  3  died — 1  from  status  Ijinphaticus;  1  from  gastro-enteritis  a 
week  after  operation  and  the  third  from  hemorrhage.  There  were  no 
perfect  anatomical  and  physiological  recoveries  but  with  few  exceptions 
the  children  made  marked  improvement  and  many  recovered  almost 
perfect  fimction. 

Taylor  also  reports  14  cases  of  the  Erb-Duchenne  tj-pe  of  paralysis 
in  adults.  Seven  showed  evidsion  of  the  roots  from  the  spinal  cord,  a 
much  higher  percentage  of  severe  injuries  than  in  the  birth  palsy  cases. 
Of  the  remaining  7,  3  were  lost  sight  of,  1  made  a  perfect  recovery; 
1  almost  perfect;  1  good  and  1  very  little  improvement,  probably 
because  he  removed  his  dressings,  stretched  his  head  from  his  neck 
and  probably  pulled  apart  the  sutured  nerves.    There  was  no  mortality. 

Nerve  Anastomosis  for  Facial  Paralysis. — ^This  operation  has  been 
successful  in  a  considerable  number  of  cases.  The  diagnosis  of  the 
forms  of  facial  paralysis  in  which  it  is  likely  to  be  helpful  is  important. 
Facial  palsy  from  "cold"  is  considered  by  Spiller  as  usually  an  infective 
neuritis  and  operation  is  usually  unnecessary.  If  the  paralysis  persists 
after  six  months  with  reaction  of  degeneration,  Spiller  recommends 
anastomosis.  The  destruction  of  the  nerve  in  operations  for  mastoid 
disease  is  the  most  frequent  indication  for  operation  and  the  history 
of  the  case  is  definite  enough  in  such  instances.  Injury  of  the  nerve 
from  gunshot  or  other  wounds  in  the  substance  of  the  parotid  after  the 
nerve  has  divided  into  smaller  branches,  would  of  course,  rule  out 
anastomosis  as  likely  to  be  a  successful  form  of  treatment. 

Treatment. — ^The  hypoglossal  nerve  is  probably  best  adapted  for  use 
and  it  is  most  conveniently  found  at  the  lower  border  of  the  digastric 
muscle  as  it  curves  forward  between  the  internal  carotid  artery  and 
jugular  vein  and  around  the  origin  of  the  occipital  artery.  The 
spinal  accessory  nerve  has  also  been  used  and  is  usually  located  by 

VOL.  I — 44 


690  SURGERY  OF  THE  NECK 

the  })r()minent  transverse  process  of  the  atlas  as  it  passes  downward 
and  backward  into  the  substance  of  the  sternomastoid  muscle  about 
two  inches  below  the  mastoid  process.  The  facial  nerve  is  located 
by  blunt  dissection  along  the  upper  part  of  the  anterior  border  of  the 
sternomastoid,  carried  down  between  the  parotid  and  anterior  border 
of  the  mastoid  process.  The  nerve  is  usually  found  less  than  one-half 
inch  from  the  surface  of  the  mastoid  and  at  the  junction  of  its  lower 
and  middle  thirds.  The  prominent  styloid  process  is  a  guide  to  its 
exit  from  the  foramen  at  its  base.  It  should  be  isolated  and  divided 
as  far  back  as  is  possible.  Another  method  is  to  incise  horizontally 
along  the  posterior  border  of  the  parotid  very  carefully  to  locate  a 
branch  which  can  be  followed  back  to  the  main  trunk.  Electrical 
stimulation  should  be  uscfl  for  identification.  End-to-end  anastomosis 
is  preferable  to  splitting  the  nerve  and  inserting  the  end  as  has  been 
suggested  by  some.  Enough  free  nerve  trunk  should  be  isolated  to 
provide  for  suture  without  tension.  The  fact  that  the  hypoglossal 
brain  center  is  more  closely  allied  to  the  facial  center,  makes  it  a  more 
satisfactory  nerve  to  use  and  Spiller  states  that  with  this  anastomosis 
it  is  possible  that  emotional  movements  may  be  restored.  The 
associated  mo^■ement  of  the  shoulder  with  the  spinal  accessory  anasto- 
mosis makes  the  result  peculiar  although  the  ultimate  result  has,  in 
certain  instances,  been  satisfactory. 

Injury  of  the  trachea  or  larynx  occurs  most  frequently  in  attempted 
suicide  by  throat-cut.  As  the  head  is  throwni  back,  the  great  vessels 
are  carried  deeply  into  the  neck  and  are  seldom  injured,  but  hi  some 
cases  the  trachea  is  laid  widely  open.  The  escape  of  frothy  blood  and 
mucus  is  more  alarming  usually  to  the  patient  and  the  bystanders  than 
to  the  surgeon.  If  the  wound  in  the  trachea  is  carefully  closed  and 
drainage  is  provided,  the  results  are  not  usually  serious,  although 
infection  almost  invariably  results  and  recovery  is  slow. 

Injury  of  the  thoracic  duct  is  mentioned  in  connection  with  the 
treatment  of  tuberculous  glands  of  the  neck,  in  which  operation  it  is 
probably  most  frequently  injured. 

DISEASES  OF  THE  NECK. 

Aneurysm  of  the  Neck. — As  the  symptomatology  of  traumatic  or 
false  aneurysm  and  the  spontaneous  or  true  aneurysm  of  the  neck  are 
practically  identical  it  seems  unnecessary  to  discuss  them  separately. 

Diagnosis. — We  have  to  consider  first;  the  distinction  between 
aneurysm  and  other  swellings  affecting  the  neck  such  as  cysts,  soft 
tumors,  abscesses  and  other  conditions  occupying  a  similar  location,  and 
second;  the  exact  fliagnosis  as  to  the  bloodvessel  which  is  affected  and 
the  location  in  the  course  of  the  bloodvessel.  Some  distinctive  symptoms 
when  present  greatly  facilitate  the  diagnosis  of  aneurysm  from  other 
timiors  of  the  neck.  These  symptoms  are  due  for  the  most  j)art  to  the 
fact  that  aneurysm  is  directly  connected  with  the  arterial  circulation. 
Pulsation  may  be  transmitted  from  the  great  bloodvessels  of  the  neck 


PLATE     IX 


Applied  Anatomy  of  the  Arteries  of  the  Neek,  Shovs/ing  the  Carotid 
and  Subclavian  Arteries.     (Gray.) 


In  considering  the  removal  of  tuniors  of  the  neek,  it  is  of  greatest  iniportanee 
for  tlie  surgeon  to  bear  in  niind  the  relation  of  the  anatomical  structure  shown  in 
this  illustration,  because  this  AA/^ill  enable  hii-n  to  avoid  injuring  any  of  these 
structures   unintentionally. 


DISEASES  OF  THE  NECK  691 

to  overlying  tumors  but  in  true  aneurysm  there  is  generally  expansile 
pulsation.  The  tumor  is  readily  compressible  and  the  pulsation  ceases 
upon  pressure  oyer  the  main  vessels,  between  the  heart  and  the  aneu- 
rysm, in  case  this  is  possible.  On  auscultation  the  bruit  in  many  cases 
is  distinctive  and  the  aspiration  of  blood  from  the  tumor  is  very  sug- 
gestive. Some  or  all  of  these  relatively  characteristic  symptoms  may 
be  absent  as  a  result  of  the  fact  that  clotting  may  have  occurred  within 
the  sac  thus  preventing  expansile  pulsation,  compressibility  and  bruit. 
A  small  amount  of  blood  may  also  be  aspirated  from  some  of  the  more 
vascular  tumors,  as  sarcoma  or  vascular  cystic  goiter.  Among  the 
most  characteristic  of  the  circulatory  symptoms  concerned  with  the 
diagnosis  of  aneurysm  is  the  delay  in  beat  and  reduced  volume  in 
pulsation  of  the  bloodvessels  peripheral  to  the  growth.  Pressure 
symptoms  are  especially  noticeable  with  aneurysm  of  the  neck  because 
of  close  proximity  to  large  nerve  trunks  and  other  important  organs. 
The  symptoms  of  pressure  on  various  nerve  trunks  are  especially  sig- 
nificant. Neuralgic  pain  and  paralysis  are  frequently  seen.  Difficulty 
in  breathing  and  in  swallowing  are  common  to  certain  other  tumors 
of  the  neck.  Brain  symptoms  due  to  disturbance  of  the  circulation  are 
more  common  than  with  most  other  growths  of  the  neck.  Pressure  of 
the  large  aneurysmal  sac  may  so  reduce  the  blood  supply  to  the  brain 
as  to  cause  persistent  headache,  and  in  other  cases,  faintness,  dizziness, 
insomnia  or  hemiplegia  may  be  present.  The  general  symptoms  of 
aneurysm  will  be  discussed  more  in  detail  in  the  chapter  devoted  to 
that  subject. 

The  differential  diagnosis  as  to  the  artery  affected  and  the  exact 
location  of  the  aneurysm  may  offer  great  difficulties.  Because  of  char- 
acteristic location  there  would  ordinarily  be  little  difficulty  in  dis- 
tinguishing between  an  aneurysm  of  the  external  and  internal  carotid 
from  the  subclavian  or  the  innominate.  In  differential  diagnosis  of 
aneurysms  affecting  the  carotids  it  should  be  kept  in  mind  that  the 
common  carotid  is  far  more  frequently  affected  than  either  the  external 
or  internal  carotid,  the  relative  frequency  being  about  87  per  cent,  in 
the  common  carotid  compared  with  7  per  cent,  in  the  external  and  about 
6  per  cent,  in  the  internal  carotid.  Difficulty  in  breathing  and  in 
swallowing  is  somewhat  frequent  with  the  larger  aneurysms  affecting 
the  common  and  internal  carotid,  much  less  frequent  with  aneurysms 
of  the  external  carotid  unless  they  are  of  large  size.  Symptoms 
from  disturbance  of  circulation  of  the  brain  may  be  present  in  either 
aneurysm  of  the  common  or  internal  carotid  but  would  be  unusual 
with  the  external  carotid.  On  account  of  their  location  higher  up  in  the 
neck,  external  and  internal  carotid  aneurysms  sometimes  cause  pres- 
sure inward  on  the  tonsils,  which  may  be  mistaken  for  a  peritonsillar 
abscess  or  tumor  of  the  tonsil.  Paralysis  of  the  hypoglossal  nerve  may 
be  present  in  any  of  the  carotid  aneurysms.  Paralysis  of  the  recurrent 
nerve  with  hoarseness  is  more  frequent  in  aneurysm  of  the  common 
and  internal  carotid.  The  sympathetic  nerves  or  the  cervical  plexus 
may  be  affected  by  aneurysms  of  the  common  or  internal  carotid, 


692  SURGERY  OF  THE  NECK 

less  frequently  by  aneurysms  of  the  common  carotid.  Pressure  on  the 
spinal  accessory  nerve  is  far  more  common  in  aneurysm  of  the  external 
carotid.  Delay  and  decreased  force  of  the  temporal  pulse  are  usual 
when  the  common  or  external  carotid  is  affected,  but  not  usual  with 
involvement  of  the  internal  carotid.  The  differential  diagnosis  of 
aneurysm  of  the  innominate  artery  from  that  of  the  common  carotid 
may  offer  great  difficulty,  especially  if  it  is  located  near  the  origin  of 
the  common  carotid.  The  relative  frequency  is  about  the  same. 
Pressure  symptoms  causing  difficulty  in  swallowing  and  breathing 
would  be  present  with  either,  also  pressure  symptoms  affecting  the 
recurrent  nerve  and  brachial  plexus.  Brain  symptoms  would  be  some- 
what more  frequent  with  the  aneurysm  of  the  common  carotid.  De- 
layed pulse  and  decreased  volume  would  be  present  in  both  the  radial 
and  temporal  arteries  in  case  of  aneurysm  of  the  innominate,  while 
only  the  temporal  artery  would  be  affected  with  aneurysm  of  the 
common  carotid.  This  is  perhaps  the  most  distinctive  of  the  symptoms 
in  the  differential  diagnosis  between  these  two  forms  of  aneurysm.  The 
differential  diagnosis  between  aneurysm  of  the  innominate  and  the 
first  portion  of  the  subclavian  would  also  offer  great  difficulties  in 
certain  cases.  Both  cause  pressure  on  the  brachial  plexus,  but  pressure 
on  the  recurrent  nerve  is  more  common  with  innominate  aneurysm, 
while  both  cause  difficulty  in  swallowing  and  breathing,  the  innominate 
perhaps  somewhat  more  frequently.  Delayed  pulse-rate  and  decreased 
force  should  be  present  in  the  radial  artery  in  case  of  aneurysm  of  the 
subclavian  and  in  both  radial  and  temporal  arteries  with  the  innomin- 
ate aneurysm.  Aneurysm  of  the  third  portion  of  the  subclavian  would 
offer  less  difficulty  because  of  its  more  characteristic  location.  In 
addition  to  the  symptoms  which  are  present  with  aneurysm  of  the 
first  portion  of  the  subclavian,  pressure  on  the  clavicle,  which  may 
cause  dislocation  in  some  cases,  should  also  be  mentioned.  i\.neurysm 
of  the  vertebral  artery  is  extremely  rare,  only  one  case  having  been 
reported  concerning  the  portion  of  the  artery  which  lies  within  the  bony 
canal  between  the  origin  of  the  artery  and  its  exit.  Traumatic  aneu- 
rysms of  the  extracranial  portion  of  the  artery  are  also  very  unusual,  the 
symptoms  closely  resembling  those  of  aneurysm  of  the  internal  carotid 
artery.  Pressure  on  the  tonsil  would  perhaps  be  considerably  less 
frequent  with  aneurysm  of  the  vertebral  artery  and  brain  symptoms 
possibly  about  equally  common. 

Treatment.^ — The  merits  of  the  various  methods  of  ligation  will  be  dis- 
cussed in  detail  in  the  chapter  dealing  with  the  general  subject  of  treat- 
ment of  aneurysms  also  aneurysm orraphy,  apparently  the  ideal  method 
recently  suggested  by  Matas;  wiring  the  sac;  and  the  use  of  the  electrol- 
ysis, gelatin  injection,  etc.  The  technic  of  ligation  will  be  discussed 
under  the  various  bloodvessels  as  such  ligations  are  required  in  the 
treatment  of  injuries  of  the  bloodvessels  and  various  other  pathological 
conditions  as  well  as  with  aneurysm.  The  various  forms  of  carotid 
aneurysms  and  also  aneurysm  of  the  third  portion  of  the  subclavian 
have  been  treated  by  compression  with  success  in  a  number  of  cases. 


PLATE    X 


First  acrtic  intercostal 


The  Internal  Carotid  and  Vertebral   Arteries.     Right  Side. 

(Gray.) 


DISEASES  OF  THE  NECK  693 

Digital  compression  is  probably  the  safest  method  of  treatment,  but 
it  is  difficult  to  carry  out  and  by  no  means  free  from  risk.  The  possi- 
bilities of  the  clot  forming  an  embolus  to  be  carried  to  the  brain  must 
always  be  borne  in  mind.  There  are  also  numerous  important  struc- 
tures in  the  neck  which  are  likely  to  be  injured  by  prolonged  compres- 
sion. A  further  disadvantage  is  that  the  treatment  is  apt  to  be  very 
painful,  and  because  of  this  it  has  been  abandoned  m  some  cases  and 
resort  has  been  made  to  ligature.  Several  successes  have  been  reported, 
however,  in  this  treatment  of  aneurysm  of  the  common  carotid  artery, 
and,  while  it  is  successful  in  obliterating  the  sac,  usually  a  channel  is 
left  through  which  the  blood  circulates,  which  is  a  further  advantage 
in  the  use  of  the  method.  Successes  have  also  resulted  from  central 
ligature  applied  according  to  the  method  of  Hunter  and  also  that  of 
Anel.  The  risk  of  this  method,  however,  is  considerably  greater  than 
of  treatment  by  compression.  Ligation  above  and  below  the  sac 
according  to  the  method  of  Antyllus  gives  prompt  results  but  is  differ- 
ent and  attended  by  considerably  risk.  The  Matas  method  would 
not  seem  to  be  any  more  difficult  to  carry  out,  and  theoretically  more 
ideal  in  every  respect.  He  reported  at  the  International  Congress  of 
Medicine,  in  1913,  7  aneurysmorraphies  for  subclavian  aneurysm,  all 
successful  and  4  carotid  with  1  accidental  death  from  coronary  disease : 
results  not  approached  by  any  other  method  to  date.  The  danger 
of  gangrene  of  the  upper  extremity  must  be  considered  when  any 
method  of  ligation  is  to  be  used.  Whenever  blood-pressure  in  the 
extremity  falls  below  35  mm.  of  mercury  there  is  considerable  danger 
of  gangrene.  To  test  the  results  of  this  method  Matas  had  used 
an  almniaum  band  which  has  been  also  tried  experimentally  by 
Halsted  and  others,  and,  in  case  there  is  risk  of  gangrene,  the  clamp 
can  be  removed  after  three  or  four  days  without  danger  to  the  artery. 
Aneurysms  located  near  the  ^origin  of  the  common  carotid  artery 
are  treated  in  the  same  way  as  aneurysms  of  the  innominate.  Aneu- 
rysms of  the  external  and  internal  carotid  have  been  treated  most 
frequently  by  ligation  of  the  common  carotid,  especially  if  they 
are  located  near  the  bifiucation  of  the  common  carotid.  This  is  a 
safer  procedure  probably  than  the  attempt  to  ligate  the  vessel  involved 
nearer  to  the  sac.  In  treatment  of  aneurj'sm  of  the  innominate 
artery  peripheral  ligation  according  to  the  method  of  Brasdor  or 
Wardrop  have  been  most  commonly  used.  In  recent  years  wiring  and 
electrolysis  have  been  used  in  a  number  of  cases  and  w^ith  success  by 
Stewart  and  Salmger,  Finney  and  others.  In  case  peripheral  ligation  is 
used  it  would  probably  be  safer  to  ligate  the  carotid  first,  so  that 
embolism  of  the  brain  would  be  less  likely.  Aneurysm  of  the  sub- 
clavian artery  has  been  treated  by  compression,  by  ligation,  also  by 
double  ligation  and  excision  according  to  the  method  of  Antyllus.  In 
case  it  is  located  near  its  origin  from  the  innominate,  peripheral  ligation 
has  been  resorted  to  in  many  cases.  It  would  seem  that  the  method  of 
Matas  in  many  cases  would  be  better  suited  than  any  of  the  methods 
of  ligation  which  have  been  previously  used.    In  case  of  aneurysm  of 


694  SURGERY  OF   THE  NECK 

the  vertebnil  artery  liji;ati(>n  according  to  the  method  of  Hunter  can 
usually  be  carried  out,  and  because  of  the  artery's  location  it  would  be 
the  best  method  in  the  majority  of  cases. 

The  ?tatistics  as  to  the  results  of  treatment  of  aneurysm  are  made 
up  for  the  most  part  from  cases  operated  upon  in  the  early  antiseptic 
days,  in  some  cases  from  work  done  in  pre-antiseptic  days  and  for  this 
reason  they  probably  seem  more  discouraging  than  they  actually  are 
at  present.  The  non-operative  methods  of  treatment,  prolonged  rest 
in  bed,  the  use  of  potassium  iodide  and  dieting,  and  the  intravenous 
use  of  gelatin  to  induce  clotting  frequently  give  relief  l)ut  probably 
■seldom,  if  ever,  result  in  cure.  These  methods  of  Valsalva,  Tufnell 
and  Balfour  are  much  less  in  favor  since  the  introduction  of  antiseptic 
surgery. 

Actinomycosis. — Diagnosis. — Actinomycosis  of  the  neck  has  to  be 
distinguished  from  subacute  or  chronic  infections  caused  by  ordinary 
pyogenic  organisms;  from  tuberculous  infections;  from  carcinoma  or 
sarcoma;  and  from  tertiary  s\'philis.  It  could  usually  be  distinguished 
from  pyogenic  infections  by  its  extremely  chronic  course,  although  in 
certain  cases  the  infection  is  a  mixed  one  and  in  such  cases  there  might 
be  considerable  difficulty.  The  location  of  the  infection  in  the  upper 
part  of  the  neck,  more  frequently  than  any  other  part  of  the  body  except 
the  mouth  and  jaw  in  the  beginning,  might  be  of  some  help.  The  disease 
frequently  finds  entrance  through  carious  teeth  and  spreads  from  the 
mouth  and  jaw  to  the  upper  part  of  the  neck  in  the  region  of  the  angle 
of  the  jaw,  along  the  lower  border  of  the  jaw  or  under  the  chin.  Actino- 
mycosis is  ordinarily  a  superficial  infection,  not  involving  the  glands 
of  the  neck  as  do  the  acute  infections,  tuberculosis,  malignancy  and 
syphilis.  Aside  from  its  origin,  superficial  location  and  chronic  course, 
the  boardlike  hardness,  alternating  with  soft  areas  when  the  growth 
breaks  down,  is  somewhat  characteristic.  The  skin  in  the  region  of  the 
soft  areas  is  usually  a  livid  purple  color.  The  growth  is  not  as  sharply 
delimited  and  it  tends  to  break  down  and  heal  with  the  formation  of  a 
good  deal  of  scar  tissue.  Absolutely  diagnostic  is  the  discovery  by 
microscopic  examination  of  the  characteristic  ray  fungus.  The  lack 
of  any  definite  limitation  of  the  growth,  the  tendency  to  soften  and 
break  down  and  discharge  material  containing  ray  fungus,  and  the 
lack  of  original  glandular  involvement  would  usually  give  no  difficulty 
in  distinguishing  the  growth  from  sarcoma  or  carcinoma  of  the  neck. 
From  tuberculosis  it  differs  in  the  usual  superficial  location  of  the 
growth,  while  tuberculosis  frequently  involves  the  deeply  seated  glands 
along  the  great  bloodvessels  of  the  neck.  It  also  differs  from  tuber- 
culosis in  hardness,  lack  of  limitation  and  the  tendency  of  certain  areas 
to  soften  and  break  down.  Reaction  to  the  tuberculin  test  and  espe- 
cially finding  the  ray  fungus  would  distinguish  it  in  any  case.  In  case 
the  primary  infection  is  located  in  the  tonsil,  the  swelling  maybe  deep- 
seated,  and  in  these  cases  in  the  absence  of  an  external  opening,  actino- 
mycosis is  almost  certain  to  be  mistaken  for  tuberculosis,  especially 
if  the  primary  lesion  in  the  tonsils  may  be  so  small  as  to  be  overlooked. 


DISEASES  OF   THE  NECK  695 

In  these  cases,  however,  the  characteristic  appearance  of  the  infected 
tissues  at  the  time  of  operation  is  hkely  to  result  in  a  correct  diagnosis. 
If  tertiary  s^'phihs  is  suspected  the  ^Yassermann  reaction  should  be 
used  before  specific  treatment  is  given,  as  actinomycosis  reacts  favor- 
ably to  antis^'philis  treatment,  also,  and  this  might  give  considerable 
difficulty  in  distinguishing  it  from  tertiary  s\'philis. 

Treatment. — ^The  treatment  is  usually  successful  if  undertaken  early 
and  persisted  in.  Incision  and  curetting  out  with  the  sharp  curette, 
the  part  of  the  gro'^'th  which  has  softened,  swabbing  with  pure  carbolic 
and  packing  with  mildly  antiseptic  gauze  is  ordinarily  all  that  is 
needed.  The  use  of  the  actual  cautery  or  of  very  caustic  chemicals  is 
probably  undesirable  and  unnecessary  in  the  majority  of  cases.  The 
iodide  of  potassium  and  other  iodides  have  been  extensively  used  both 
by  mouth  and  by  injection  directly  into  the  growth.  There  is  a  wide- 
spread belief  that  the  use  of  the  iodides  has  a  favorable  influence  on 
actinomycosis  and  practically  all  patients  receive  these  remedies 
usually  internally,  but  occasionally  injected.  AMien  injected  into  the 
growth  a  1  per  cent,  solution  of  the  iodide  of  potassium  is  ordinarily 
used,  injected  either  daily  or  at  somewliat  longer  intervals.  In  other 
cases  2  or  3  drams  of  Lugol's  solution  has  been  used  in  place  of  iodide 
of  potassium.  The  use  of  some  of  the  iodides,  especially  the  iodide  of 
potassium,  in  connection  with  surgical  treatment  would  be  desirable 
on  the  basis  of  experience  of  many  observers.  Small  doses  are  valueless, 
60  to  90  gr.  followed  by  a  pint  of  hot  water  at  eight-hour  intervals, 
t.  i.  d.  for  three  days;  then  a  week  of  rest,  continued  for  six  weeks; 
then  three  days'  treatment  each  month  for  six  months,  have  given 
permanent  cure  without  operation  in  some  cases.  Early  and  persistent 
treatment  is  desirable  in  order  that  spread  of  the  gro-^^h  may  be 
prevented.  AYhile  the  tendenc}'  is  toward  superficial  involvement, 
occasional  cases  have  occurred  in  which  the  growth  has  spread  along 
the  fascia  and  deep  bloodvessels  of  the  neck  mvolvmg  the  medi- 
astinum or  occasionally  the  pleura  and  lungs.  Spread  of  the  disease 
upward  along  the  spinal  column  toward  the  base  of  the  skull  and  the 
brain  with  fatal  outcome  has  also  been  observed  in  neglected  cases. 
If  the  disease  goes  on  for  a  considerable  time  the  prolonged  suppuration 
also  has  a  tendency  to  cause  amyloid  degeneration  of  the  parenchy- 
matous organs,  and  dangerous  cachexia.  Swabbing  the  wound  after 
incision  and  curettement  with  some  mildly  caustic  antiseptic  solution 
also  tends  to  sear  the  tissues  and  prevent  reinfection  of  the  wound  and 
further  spread  of  the  disease.  It  is  perhaps  unusual  to  get  a  cure  by 
one  or  two  energetic  treatments,  but  if  treatment  is  persisted  in  and  is 
made  as  thorough  as  possible  there  have  been  an  encouraging  number 
of  cures  reported. 

Syphilis. — All  the  tissues  of  the  neck  are  liable  to  involvement  in 
tertiary  sA^philis.  Ulceration  of  the  skin,  involvement  of  the  Ijinphatic 
glands,  periostitis  of  the  hyoid,  and  chondritis  of  the  laryngeal  cartilages 
have  been  reported.  Primary  and  secondary  s}-philis  causes  involve- 
ment of  the  l\Taphatic  glands  of  the  neck  as  a  rule.    ^Modern  laboratory 


696  SURGERY  OF  THE  NECK 

studies  have  contributed  greatly  to  the  accuracy  of  diagnosis  in  difficult 
cases.  A  four  plus  positive  Wassermann  reaction  or  demonstration 
microscopically  of  the  Spirocheta  pallida  in  the  secretions  from  chancre, 
moist  papules  or  mucous  patches,  give  definite  diagnosis,  if  obtained. 
The  clinical  history  may  be  so  clear  as  to  make  laboratory  diagnosis 
almost  unnecessary  in  some  cases.  In  doubtful  cases  careful  inquiry 
should  be  made  into  the  history,  no  matter  what  the  social  standing  or 
position  in  life  of  the  patient,  and  frequently  there  will  be  brought  out  a 
history  of  some  or  all  of  the  characteristic  lesions:  an  indolent  sore,  skin 
eruptions,  falling  of  the  hair,  sore-throat,  cachexia  and  general  glandular 
involvement.  In  extragenital  s\'philis  the  lymphatic  glands  of  the 
neck  are  involved  more  frequently  than  any  other  group  in  the  body. 
The  submental,  submaxillary  glands  and  those  above  the  angle  of  the 
jaw  are  most  frequently  affected  with  primary  lesion  of  the  lip,  the 
tongue  or  the  tonsils.  The  symptoms  of  glandular  involvement  in  the 
neck  are  considerably  more  acute  as  a  rule  than  the  involvement  of 
the  glands  of  the  groin.  Sometimes  there  is  a  good  deal  of  pain,  con- 
siderable adenitis  and  the  tumor  may  reach  the  size  of  a  goose  egg. 
It  may  be  somewhat  fixed  by  infiltration  of  the  surrounding  tissues. 
The  appearance  of  such  glandular  enlargement  rather  suddenly  in  a 
person  formerly  in  good  health,  especially  if  a  primary  lesion  can  be 
located  in  the  region  of  the  mouth,  is  quite  suggestive,  and  usually  with 
the  help  of  modem  laboratory  methods  there  would  be  little  difficulty 
in  diagnosis  of  acute  involvement  of  the  glands  from  ordinary 
infectious  causes.  In  secondary  syphilis  there  would  be  a  general 
glandular  enlargement  as  well  as  of  the  glands  of  the  neck;  enlargement 
is  rarely  so  great  as  with  primary  sj^Dhilis,  usually  not  larger  than  a 
pea;  and  the  glands  are  hard,  freely  movable  and  painless.  The 
clinical  history  and  s;^Tnptoms  usually  leave  little  doubt  as  to  the  char- 
acter of  the  glandular  enlargement  and  the  diagnosis  could  be  confirmed 
by  laboratory  methods.  In  tertiary  sj'philis  ulceration  of  the  skin  is 
not  so  very  uncommon;  the  ulcer  is  usually  painless  and  extremely 
indolent  in  its  course;  the  contour  is  irregular  and  ragged,  and  the 
edges  are  undermined  and  the  base  covered  by  secretion.  Usually 
there  is  little  difficulty  in  diagnosis  from  ulcers  of  other  causes  if  the 
history  is  carefully  taken.  The  historj^  of  an  injury  or  bum;  the  small 
scab  coming  off  and  leaving  a  bleeding  surface  which  gradually  enlarged 
in  the  case  of  epithelioma  and  the  characteristic  appearance  of  lupus 
are  usually  sufficiently  diagnostic.  Of  the  deeper  soft  parts,  the  muscles 
of  the  neck  are  sometimes  affected  in  tertiary  sj-philis,  the  stemo- 
mastoid  very  much  more  frequently  than  any  other  muscle.  The  myo- 
sitis may  be  of  a  diffuse  sclerosing  form  or  more  frequently  a  gummat- 
ous tumor  appears.  The  lower  part  of  the  muscle  is  most  frequently 
affected  and  the  involvement  may  be  symmetrical.  There  is  rarely 
any  disturbance  of  function  and  little,  if  any,  pain.  There  are  rather 
rare  cases  of  gummatous  glandular  involvement  in  the  tertiary  stage. 
These  tumors  grow  very  slowly;  are  not  painful,  either  spontaneously 
or  upon  pressure;  the  consistency  is  firm  and  elastic  and  there  are  no 


DISEASES  OF  THE  NECK  697 

adhesions  to  surrounding  tissues  except  that  in  the  later  stages  the  skin 
is  sometimes  involved  and  breaks  through  forming  characteristic 
ulcers.  As  the  other  manifestations  of  syphilis  are  usually  past  at  this 
stage^  the  diagnosis  may  be  somewhat  more  difficult,  but  the  Wasser- 
mann  reaction  would  be  of  great  help  in  such  cases.  There  have  been 
extremely  rare  cases  of  sjT^hilis  affecting  the  hyoid  bone  and  also  the 
cartilages  of  the  larynx.  Either  single  or  multiple  periosteal  nodes  may 
appear.  These  are  either  isolated  or  appear  in  connection  with  chon- 
dritis of  the  thyroid  cartilage.  In  certain  cases  there  is  considerable 
pain  with  sw^allowing,  difficulty  in  speaking  and  some  difficulty  in  the 
movements  of  the  head  and  neck. 

Treatment. — The  use  of  salvarsan  intravenously  or  of  neosalvarsan  has 
given  great  improvement  in  results  in  treatment  of  all  forms  of  syphilis. 
There  has  been  some  disappointment  in  the  fact  that  one  treatment 
is  not  always  sufficient,  but  if  the  treatments  be  repeated  until  sev- 
eral negative  Wassermanns  are  obtained  the  patient  may  be  considered 
cured.  Many  advise  using  active  mercurial  and  iodide  treatment  in 
connection  with  the  salvarsan.  Active  operative  measures  would  of 
course  be  contra-indicated  in  case  the  positive  diagnosis  of  syphilis 
were  possible.  Ulcers  or  broken  down  gummas  should  be  treated  by 
ordinary  antiseptic  measures  and  usually  heal  promptly  under  suitable 
antisyphilitic  treatment.  Attention  to  the  general  health  of  the  patient 
should  not  be  neglected  in  connection  with  the  specific  treatment  of 
syphilis — ^hygienic  measures  and  general  tonics  are  sometimes  of  great 
value. 

Chronic  Inflammatory  Processes  Affecting  the  Neck. — Chronic 
inflammatory  conditions  in  the  neck  are  most  commonly  of  specific 
origin,  chiefly  tuberculosis,  also  actinomycosis  and  syphilis.  While  these 
specific  infections  form  the  great  bulk  of  such  conditions,  certain 
chronic  inflammations  are  caused  by  one  or  more  of  many  pyogenic 
organisms.  The  so-called  ligneous  abscess  "phlegmone  ligneuse"  of 
Reclus  is  probably  of  such  origin,  the  infection  being  too  attenuated 
to  produce  much  pus  but  keeping  up  a  prolonged  inflammation  result- 
ing in  dense,  board-like  hardness.  There  is  little  tenderness,  pain, 
fever  or  tendency  to  suppuration;  it  may  remain  stationary  for  long 
periods;  incision  may  show  purulent  exudate  in  the  intermuscular 
spaces.  Simple  hj'perplastic  enlargement  of  the  glands  of  the  neck, 
chronic  lymphadenitis,  is  not  infrequently  seen  as  the  result  of  some 
irritation  in  the  skin  of  the  scalp  or  neck,  mucous  membranes  of  the 
mouth  or  throat,  or  tonsils  and  adenoids,  and  the  accessory  sinuses. 
The  differential  diagnosis  has  to  be  made  from  the  cysts  and  solid 
tumors  of  the  neck;  from  tuberculosis,  actinomycosis  and  syphilis;  and 
from  the  metastatic  glandular  involvement  in  the  malignant  tumors, 
especially  those  which  are  located  with  difficulty  in  the  pharynx  or 
esophagus.  A  positive  diagnosis  is  frequently  impossible  even  if  the 
glands  are  removed  and  examined  microscopically.  The  Wassermann 
four  plus  reaction,  the  tuberculin  test,  and  the  appearance  of  the  ray 
fungus  in  the  pus  from  actinomycosis,  would  be  sufficient  to  give  a  posi- 


698 


SURGERY  OF  THE  NECK 


live  diagnosis,  if  present.  The  age  of  the  patient  would  l)e  of  some  help 
in  case  malignancy  were  under  consideration,  malignant  growths  usually 
att'ecting  i)atients  in  adult  life  or  older,  while  the  chronic  hyperplastic 
intlamniations  are  far  more  frecpiently  seen  among  children,  especially 
among  young  children.  The  enlargements  are  frequently  small  and 
multiple,  while  with  cysts  or  solid  tumors  of  the  neck  the  growth  is 
usually  single  and  larger.  The  characteristic  location  might  be  of  some 
help  in  differential  diagnosis  from  certain  cysts.     Aberrant  thyroids 

are  usually  larger,  though  the  loca- 
tion may  be  similar.  Dermoid 
timiors  of  the  neck  are  always 
single  and  located  in  the  submax- 
illary region.  The  presence  of 
some  source  of  chronic  irritation, 
especially  eczema  of  the  skin  of 
the  scalp  or  neck,  pyorrhea  alveo- 
laris,  tonsillitis,  enlarged  adenoids, 
or  chronic  disease  of  the  sinuses 
might  be  evident  causes  of  possible 
glandular  enlargement.  !£uch  en- 
largement from  some  cause  of 
chronic  irritation  would  usually 
disappear  unless  necrosis  or  pus 
formation  had  occurred  when  the 
cause  was  removed.  In  case  of 
doubtful  diagnosis  the  cause  of  the 
supposed  irritation  should  be  re- 
moved and  the  case  kept  under 
observation.  If  there  is  doubt  as 
to  tuberculosis,  malignancy  or 
Hodgkin's  disease,  a  gland  might 
be  removed  for  examination. 

Treatment. — Usually  the  removal 
of  the  cause  is  suflGcient  to  give 
relief.  If  the  enlargement  persists, 
especially  if  there  is  doubt  as  to 
the  diagnosis,  excision  of  an  en- 
larged gland  would  be  advisable. 
Attention  to  the  general  health, 
good  nourishing  food,  fresh  air, 
bathing  and  use  of  suitable  tonics  would  be  of  a  good  deal  of  value  in 
many  of  these  cases  as  well  as  in  the  treatment  of  tuberculosis.  Painting 
the  skin  overlying  the  glands  with  tincture  of  iodin,  rubbing  in  various 
iodin  salves,  or  the  use  of  mercurial  ointment,  are  favorite  measures 
in  the  hands  of  many  observers  and  have  the  value  of  harmlessness, 
unless  the  skin  is  blistered  or  the  tissues  otherwise  injured.  If  soften- 
ing and  other  evidence  of  pus  are  present,  incision  and  drainage  are  of 
course  necessary. 


Fig.  492. — Woody  or  ligneous  phlegmon 
of  neck.  Struck  by  steel  two  months  ago. 
Slow,  painless  onset  ot  induration,  which 
extends  Irom  mandible  nearly  to  clavicle, 
and  from  larynx  to  anterior  border  of  tra- 
pezius. Skin  red,  slight  edema,  and  pitting 
on  pressure.  No  tenderness.  Poulticed 
for  three  days,  then  incised.  Rapid  re- 
covery.   Episcopal  Hospital.    (Ashhurst.) 


PLATE    XI 


Posterior 

auricular 

glands 


Maxillary  glands 


Parotid  glands 
Buccinatcr  glands 


Supramandibular 

glands 
Submaxillary 
glands 

Submental  glands 


Inferior  deep 
cervical  glands 


Superficial   Lymph  Glands  and  Lymphatic  Vessels  of    Head 
and  Neck.     (Gray.) 


DISEASES  OF   THE  NECK  699 

Tuberculous  Cervical  Lymphadenitis. — Before  the  discovery  of 
tubercle  bacilli  such  involvemeut  of  the  glands  of  the  neck  was  spoken 
of  as  scrofulous  swelling,  and  in  the  pre-antiseptic  days  many  forms 
of  treatment  were  in  vogue  which  gave  a  fair  percentage  of  cures, 
probably  more  because  of  the  resistance  of  the  patients  and  infection 
of  low  virulence  than  because  the  methods  had  any  particular  virtue. 
Recent  publications,  especially  those  of  Demme  of  the  -Tenner  Children's 
Hospital  in  Berne,  and  those  of  Dowd  and  Mitchell  have  shown  that 
serious  disease  of  other  organs  of  the  body  especially  the  lungs  is  likely 
to  follow  neglected  tuberculosis  of  the  glands  of  the  neck  and  that 
radical  removal  offers  by  far  the  best  prospect  of  relief. 

Diagnosis. — Ihe  clinical  picture  of  tuberculous  glands  of  the  neck  is 
so  varied  that  there  are  occasional  cases  in  which  a  positive  diagnosis 
is  difficult.  We  may  find  anything  from  moderate-sized  freely  movable, 
enlargement  of  a  single  gland  to  extensive  involvement  of  the  entire 
chain  on  both  sides  of  the  neck,  som.etimes  with  extensive  abscess 
formation  or  old  discharging  fstulie.  Generally  an  entire  group  of 
glands  is  enlarged,  the  individual  glands  varying  greatly  in  size  and 
matted  together  by  the  inflammatory  periadenitis.  There  is  usually 
little,  if  any,  tenderness  or  pain  unless  there  is  a  mixed  infection. 
The  constitutional  symptoms  are  not  severe.  Fever  is  not  present  as  a 
rule  and  frequently  there  is  little,  if  any,  loss  of  weight  and  strength. 
Patients  at  all  ages  of  life  may  be  affected,  although  the  condition  is 
more  common  in  children.  The  general  tests  for  tuberculosis  may  be 
of  value  if  it  is  possible  to  carry  them  out.  The  tuberculin  reaction  is 
reliable  if  properly  used,  but  of  course  may  indicate  tuberculosis  of 
some  other  part  of  the  body.  If  material  is  injected  into  a  guinea-pig 
the  characteristic  changes  usually  follow.  Tubercle  bacilli  are  not 
often  obtained  by  smear  or  culture  from  the  pus  of  broken-down  glands 
and  are  very  difEcult  to  demonstrate  in  microscopic  sections.  Ana- 
tomical tubercles  are  usually  readily  found  in  microscopic  sections. 
The  gross  appearance  of  caseous  or  broken-down  glands  is  fairly 
characteristic. 

Other  conditions  causing  glandular  enlargement  should  first  be  borne 
in  mind  in  the  dift'erential  diagnosis.  The  general  glandular  enlarge- 
ment of  syphilis,  especially  if  the  epitrochlear  or  other  unusual  glands 
are  involved,  usually  gives  little  difficulty.  The  history  of  chancre, 
characteristic  lesions  of  the  skin  and  its  appendages  and  of  the  mucous 
membranes,  would  make  the  diagnosis  still  more  certain.  In  doubtful 
cases  the  Wassermann  reaction  should  always  be  used. 

Leukemia  or  pseudoleukemia  could  be  ruled  out,  if  there  were  any 
doubt,  by  the  blood  examination.  Malignant  lymphoma,  lympho- 
sarcoma or  Hodgkin's  disease  may  give  considerable  difficulty  in  early 
cases.  Later  in  the  disease  extensive  glandular  involvement  with 
rather  characteristic  appearance  of  the  neck  and  the  effect  on  the 
general  health  would  be  very  suggestive.  The  glands  are  also  much 
more  likely  to  be  freely  movable  than  with  tuberculosis,  in  which  the 
masses  are  somewhat  fixed  by  periadenitis  when  the  enlargement  has 


700  SURGERY  OF  THE  NECK 

reached  considerable  size.  In  doubtful  cases  a  gland  should  be  removed 
for  microscopic  examination.  Metastatic  involvement  of  the  glands 
from  carcinoma  would  ordinarily  offer  no  serious  difficulties  in  diag- 
nosis. The  occasional  cases  of  primary  carcinoma  are  much  more 
difficult,  but  in  any  doubtful  case  a  thorough  excision  should  be  under- 
taken. In  the  broken-down  glands  of  actinomycosis  the  characteristic 
microscopic  appearance  of  the  pus  would  settle  the  diagnosis.  Enlarge- 
ment of  the  thyroid  would  ordinarily  offer  no  difficulty  because  of  its 
movement  with  the  larjmx  on  swallowing,  its  characteristic  location, 
the  single  enlargement,  and  the  history  of  the  case.  The  various 
cysts  of  the  neck  are  frequently  characteristic  in  their  location  and 
relation  to  other  anatomical  structures,  usually  single  and  do  not 
ordinarily  offer  much  difficulty. 


Fig.  493. — Tuberculous  glands  of  both  sides  of  the  neck,     (de  Quervain.) 

Treatment. — Various  palliative  measures  of  treatment  have  been  in 
favor  during  the  past  few  years.  The  a'-ray  treatment  has  apparently 
given  some  positive  results,  but  as  the  a'-ray  specialists  are  just  begin- 
ning to  reach  positive  conclusions  about  accurate  dosage,  it  is  still 
uncertain  just  what  the  value  and  limitations  of  this  method  of  treat- 
ment should  be.  Apparently  it  has  given  best  results  in  less  advanced 
cases  where  there  is  no  caseation,  certainly  no  pus  formation,  in  other 
words  the  cases  which  have  given  very  favorable  results  with  general 
constitutional  measures,  in  many  of  which  there  may  have  been  only 
hyperplasia  without  actual  tuberculosis.  About  the  same  may  be 
said  of  the  therapeutic  use  of  tuberculin.  Some  writers  have  advised 
the  after-treatment  by  .r-ray  as  a  preventive  of  further  trouble.  The 
value  of  the  method  is  still  in  doubt  and  it  certainly  should  not  be  too 
long  continued  where  uncertain  results  have  been  obtained. 

Aspiration  of  the  pus  in  broken-down  glands  and  injection  of  various 


DISEASES  OF  THE  NECK  701 

antiseptics  has  had  a  number  of  advocates.  Iodoform  emulsion, 
tincture  of  iodin,  carbolic  acid,  zinc  chloride,  and  the  camphorated 
naphthol  solution  of  Calot  have  been  used.  In  certain  cases  the  anti- 
septics have  been  injected  into  glands  that  have  not  broken  down  with 
the  idea  of  producing  suppuration.  The  pus  is  then  aspirated,  further 
antiseptics  injected  and  in  certain  cases  a  compression  bandage  is 
applied.  It  is  evident  that  every  diseased  gland  must  be  treated  if 
satisfactory  results  are  to  be  obtained,  and,  considering  the  extent  of 
the  involvement  in  the  majority  of  these  cases,  it  would  seem  to  have  a 
decidedly  limited  field  of  usefulness.  Calot  admits  that  skin  ulceration 
and  scarring  very  frequently  result. 

Operative  Treatment. — Considering  the  risk  of  involvement  of  other 
parts  of  the  body,  operative  treatment  should  not  be  delayed  in  case 
reasonably  prompt  results  are  not  obtained  by  other  measures.  We 
consider  it  the  method  of  choice  in  persistent  enlargement  of  much  size. 
The  extent  of  operation  varies  widely,  depending  upon  the  location, 
duration,  and  extent  of  the  disease.  Frequently  a  group  of  enlarged 
glands  can  be  removed  through  a  small  incision  under  local  anesthesia, 
making  the  operation  a  relatively  minor  affair.  The  permanent  results 
in  such  cases  are  better  than  when  the  disease  is  neglected  until  exten- 
sive involvement  has  occurred.  It  is  entirely  possible  to  remove  all 
diseased  glands  without  an  extensive  operation  in  many  cases,  and  we 
have  a  number  of  cases  who  have  been  under  observation  from  five  to 
ten  years  after  such  local  excision  with  entire  freedom  from  recurrence. 
Considering  the  slight  extent  of  the  operation,  trifling  after-effects, 
little  scarring  and  excellent  permanent  results,  this  would  seem  to  have 
a  claim  to  be  the  operation  of  choice  in  cases  among  intelligent  people 
seen  early. 

Incision,  curetting  and  drainage  of  a  single  broken-down  gland  or  a 
small  group  of  infected  glands  may  give  permanent  results  where  there 
is  slight  involvement  of  decidedly  limited  extent.  As  with  forms  of 
tuberculosis  affecting  other  organs,  the  results  with  tuberculosis  of  the 
glands  of  the  neck  treated  in  this  way  are  especially  favorable  with 
children,  when  conditions  of  living  can  be  made  satisfactory.  With 
older  patients,  if  any  caseous  glands  are  left  behind,  suppuration  will 
usually  continue  for  weeks  or  months  until  the  diseased  tissue  is  thrown 
off,  leaving  very  disfiguring  scars  and  decided  risk  of  tuberculous 
involvement  of  other  parts  of  the  body. 

Complete  Excision  of  the  Glands  of  the  NecJc. — Under  this  heading 
may  be  included  complete  excision  of  any  of  the  larger  groups  of  glands 
not  necessarily  including  the  dissection  of  both  triangles  of  the  neck 
where  the  disease  is  limited  to  one  only.  The  adjective  complete  should 
refer  to  removal  of  the  disease  rather  than  extent  of  operation.  The 
normal  incisions  suggested  by  Kocher,  placed  along  the  line  of  natural 
folds  of  the  neck,  are  used  by  a  large  number  of  surgeons  who  have  had 
extensive  experience  with  this  operation.  For  the  anterior  triangle  of 
the  neck  the  incision  is  placed  below  the  lower  border  of  the  jaw  about 
one  or  two  finger-breadths,  extending  forward  from  just  below  the  tip 


702  SURGERY  OF  THE  NECK 

of  the  mastoid  process  to  the  middle  of  the  neck  or  even  beyond. 
In  case  both  the  anterior  and  posterior  chain  are  involved  a  second 
incision  may  be  placed  parallel  to  the  clavicle  over  the  lower  part  of 
the  neck,  the  double  incision  giving  far  more  satisfactory  results  as 
regards  scar  than  a  single  longitudinal  incision.  The  greatest  possible 
variety  of  incisions  has  been  recommended.  An  oblique  incision  on  the 
posterior  surface  of  the  neck,  which  may  be  placed  just  within  the 
border  of  the  hair-line,  may  be  combined  with  either  the  upper  or  lower 
transverse  incision  and  it  adds  very  little  to  the  disfigurement.  Dowd 
joins  the  incision  within  the  hair-line  with  the  upper  transverse  incision 
and  calls  it  the  elbow  incision.  This  gives  an  entirely  satisfactory 
exposure,  particularly  when  the  glands  of  the  upper  anterior  triangle 
are  most  extensively  involved.  Kriiger  joins  the  incision  along  the 
hair-line  with  the  lower  transverse  incision,  making  it  a  bow-shaped 
rather  than  elbow  incision,  and  this  gives  also  an  extremely  satisfactory 
exposure  in  case  of  extensive  involvement.  We  have  been  able  to  re- 
move extremely  adherent  masses  of  glands  in  the  region  of  the  angle  of 
the  jaw  and  at  the  bifurcation  of  the  common  carotid  artery  by  retract- 
ing the  flap  formed  by  the  low  transverse  incision  joined  to  the  incision 
within  the  hair-line,  with  entire  satisfaction.  If  the  glands  are  deep- 
seated  and  adherent,  it  is  extremely  important  to  get  a  good  exposure 
in  order  to  avoid  important  anatomical  structures  and  satisfactorily  to 
avoid  and  control  hemorrhage.  Division  of  the  sternomastoid  muscle 
gives  better  exposure,  but  is  usually  unnecessary.  The  contour  of 
the  neck  is  better  if  division  can  be  avoided.  In  the  more  extensive 
cases  a  flap  of  skin  and  underlying  platysma  muscle  is  reflected, 
and  in  case  it  seems  best  to  divide  the  sternomastoid,  that  too  can 
be  included  with  the  flap.  In  some  of  the  more  difficult  cases  the 
omohyoid  muscle  forms  a  convenient  guide  to  the  great  bloodvessel 
sheath.  Dissecting  along  the  posterior  border  of  the  sternomastoid 
muscle,  the  omohyoid  can  usually  be  readily  located,  and  by  mak- 
ing taut  the  tendinous  portion,  it  can  be  readily  followed  forward 
where  it  directly  overlies  the  internal  jugular  vein.  Once  having  located 
the  vein,  injury  is  not  likely  to  occur.  Avoidance  of  injury  to  the 
internal  jugular,  the  spinal  accessory  nerve,  and  the  lower  filament  of 
the  facial  nerve  are  emphasized  by  all  writers  on  this  subject.  To  avoid 
injury  of  the  vein  there  should  be  no  forcible  blunt  dissection  immedi- 
ately in  its  neighborhood.  Firm  packing  of  the  lower  part  of  the 
wound  has  been  suggested  to  make  the  vein  prominent  so  that  it  is 
readily  seen.  In  case  oozing  obscures  the  field  it  can  sometimes  be 
cleared  up  by  the  anesthetist's  allowing  the  patient  more  air  or  oxygen 
if  a  closed  anesthetic  apparatus  is  used.  Some  suggest  passing  ligatures 
about  the  vein  so  that  it  may  be  readily  secured  in  case  it  is  injiu-ed. 
If  the  vein  is  injin-ed  it  is  most  frequently  one  of  the  branches  that  is 
torn  off,  and  the  vein  itself  is  injured  in  an  attempt  to  secure  the  branch. 
Dowd's  suggestion,  that  it  is  better  to  pack  that  part  of  the  wound  and 
go  to  some  other  part  of  the  field  of  ojieration  for  the  time,  will  make  the 
problem  of  securing  the  bleeding  vessel  relatively  simple  in  most  cases. 


PLATE    Xn 


Parotid  glands 


Superficial  cervi-  . 
cal  glands 


Facial  glands 
Submaxillary  glands 

Deep  cervical  glands 


The  Lymphatics  of  the  Face.     (Gray.) 


DISEASES  OF  THE  NECK  703 

If  torn,  the  vein  can  be  secured  by  lateral  ligature  by  a  fine  silk  stitch 
over  clamps,  or  in  some  cases  by  an  entire  ligation  of  the  vein.  This 
ordinarily  gives  no  troublesome  results  and  from  5  to  10  per  cent,  of 
such  ligations  are  reported  by  a  number  of  surgeons.  That  it  may  not 
be  entirely  free  from  danger  is  indicated  by  three  fatalities  reported  by 
German  surgeons  and  collected  by  Dowd.  The  inspiration  of  air  can 
usually  be  avoided  by  a  compress  firmly  placed  over  the  vein  or  by 
squeezing  a  spongeful  of  saline  solution  or  sterile  water  into  the  wound, 
if  one  of  the  larger  veins  of  the  neck  is  injured. 

Injury  to  the  spinal  accessory  nerve  should  be  avoided  if  possible, 
for  paralysis  resulting  gives  very  unsightly  deformity;  drooping  of  the 
shoulder,  and  usually  tilting  outward  of  the  angle  of  the  scapula 
sometimes  spoken  of  as  "  angelfwing"  deformity.  The  nerve  frequently 
passes  directly  through  a  matted  mass  of  glands  and  when  stained 
with  blood  it  is  difficult  to  distinguish  from  the  gland  capsule,  but 
there  are  a  sufficient  number  of  reliable  anatomical  relations  that  help 
in  locating  the  nerve  so  that  injury  should  seldom  occur.  Three  of 
these  are  of  special  value:  The  nerve  passes  directly  in  front  of  the 
prominent  transverse  process  of  the  atlas  which  can  practically  always 
be  located;  it  is  covered  above  by  the  posterior  belly  of  the  digastric 
muscle  which  can  also  be  located  without  trouble;  it  runs  doTMiward 
and  backward  into  the  substance  of  the  sternomastoid  muscle  and 
slight  pinching  of  the  nerve  with  forceps  wdll  usually  cause  drawing  up 
of  the  shoulder.  The  mass  of  enlarged  glands  can  be  dissected  free  and 
dra-^Ti  down,  underneath  or  over  the  nerve,  but  sometimes  it  is  more 
convenient  to  divide  the  bunch  in  order  to  avoid  the  nerve.  Immediate 
suture  of  the  nerve  generally  results  satisfactorily  in  case  the  injury  is 
recognized. 

The  lower  facial  nerve  filament  (ramus  anastomoticus  collomandi- 
bularis  Jaffe)  when  divided  causes  disfiguring  paralysis  of  the  lower  lip 
which  is  usually  temporary  but  may  persist.  An  excellent  illustration 
from  a  dissection  made  for  Dowd  gives  the  location  of  this  filament  and 
his  rules  for  avoiding  this  branch  deserve  mention.  (1)  Transverse  inci- 
sions three-quarters  of  an  inch  below  the  angle  of  the  jaw  seldom  injure 
it,  especially  if  the  skin  is  retracted  downward  and  the  platysma  and 
deep  cervical  fascia  are  divided  at  a  lower  level.  (2)  Smce  it  crosses 
the  border  of  the  jaw  with  the  facial  artery,  incisions  in  front  of  the 
artery  do  not  touch  it.  (3)  Since  it  goes  into  the  neck  at  about 
the  anterior  border  of  the  sternomastoid  muscle,  incisions  posterior  to 
the  muscle  do  not  injure  it.  (This  is  true  of  the  vertical  branch  of  the 
elbow  incision  which  is  located  within  the  hair-line.)  (4)  Since  it  lies 
on  the  deep  cervical  fascia  and  below  the  platysma,  dissections  between 
these  structures  should  be  avoided,  and  incisions  should  be  made 
through  them  below  the  level  of  the  skin  incision  and  they  should  be 
retracted  upward  with  the  filament  between  them.  Careful  adjust- 
ment of  the  fascia  (suture  of  fascia  and  platysma)  should  be  made  at 
the  end  of  the  operation  so  as  to  favor  repair  if  any  injury  has  taken 
place. 


704 


SURGERY  OF  THE  NECK 


Injury  to  the  thoracic  duct  has  been  reported  a  number  of  times 
without  any  fatahties  or  serious  results  which  could  be  attributed  to 
this  injury.  Six  cases  were  treated  by  packing  the  wound ;  7  by  ligation 
and  2  by  suture.  ^Ye  have  one  additional  case  treated  by  packing  to 
report.  For  a  number  of  days  there  was  a  considerable  oozing  of  milky 
looking  chyle  which  gradually  decreased  and  subsided  without  mater- 
ially lengthening  convalescence.  Injury  of  the  phrenic,  pneumogastric, 
hypoglossal,  glossopharyngeal  or  s^iupathetic  nerves,  or  the  carotid 
artery,  or  its  important  branches  are  avoided  if  the  operator  keeps 
close  to  the  gland  capsule  in  his  dissection.  Division  or  injuryof  large 
branches  of  the  superficial  cervical  plexus  is  not  easily  avoided  in  many 
cases,  but  results  only  in  temporary  anesthesia  with  occasional  shooting 
pains  as  nerve  regeneration  occurs. 


Fig.  494. — Dissection  showing  lower  filaments  of  the  facial  nerve,  especially  the 
"ramus  anastomaticus  collomandibularis,"  Jaffe,  which  supplies  the  depressor  labii 
inferioris.  ^4,  cer\-icofacial  division  of  the  facial  nerve;  B,  ramus  anastomaticus  collo- 
mandibularis; C,  filament  to  platysma  myoides;  D,  parotid  gland;  E,  deep  cervical 
fascia;  F,  platysma  myoides.     (Dowd,  Annals  of  Surgery.) 

Some  authorities  advise  against  attemptmg  complete  excision  if  there 
is  abscess  formation  and  especially  if  fistulae  are  present.  The  extensive 
adhesions  in  long  standing  cases,  especially  if  there  has  been  previous 
incision  and  drainage  or  injection  treatment,  certainly  give  rise  to 
many  added  difficulties,  but  recently  an  increasing  number  of  these 
cases  are  being  radically  operated  upon.  It  is  usually  possible  to  avoid 
extensive  soiling  of  the  wound,  if  it  is  packed  with  gauze  to  protect 
clean  areas  and  the  pus  is  mopped  up  immediately  when  encountered 
with  the  least  possible  smearing  and  soiling  of  instruments  and  pro- 
tective dressings.     If  all  broken-dowii  material  is  carefully  removed 


DISEASES  OF  THE  NECK  705 

with  a  curette  while  the  main  wound  is  so  protected  and  the  cavity 
remaining  is  stuffed  with  a  sponge  soaked  in  some  antiseptic  solution, 
it  is  possible  to  proceed  with  a  clean  block  dissection  which  will  remove 
practically  all  diseased  glands  and  the  resulting  extensive  wound 
usually  heals  without  much,  if  any,  delay.  Of  course  in  such  cases  it  is 
especially  important  to  provide  for  free  drainage.  Even  in  the  cases 
in  which  it  is  possible  to  do  a  perfectly  clean  dissection,  drainage  is 
desirable,  for  dividing  many  lymph  channels  is  unavoidable  and  there 
is  rather  profuse  drainage  of  lymph,  serum  and  some  oozing  blood. 
The  drainage  should  be  removed  within  the  first  few  days  or  permanent 
sinuses  may  result.  To  avoid  disfiguring  scar,  a  separate  drainage 
opening  should  be  made  near  the  base  of  the  neck,  just  above  the 
clavicle  or  below  the  sternal  notch.  A  thick  moist  dressing  encourages 
drainage,  especially  in  the  infected  cases  and  should  be  changed  fre- 
quently at  first.  The  writer  has  used  Carrel-Dakin  treatment  with 
rapid,  clean  healing  in  several  cases  with  abscess  formation.  The 
main  incisions  are  sutured  and  thin  gauze  strips  are  used  just  sufficient 
to  separate  infected  planes.  Gauze  strips  and  Carrel-Dakin  tubes  are 
both  inserted  through  independent  drainage  openings.  Careful  arrest 
of  hemorrhage  by  securing  all  bleeding  points  with  ligature  is  impor- 
tant. A  special  stitch  approximating  the  platysma  and  fascia  improves 
the  appearance  of  the  scar.  Subcutaneous  skin  closure  avoids  stitch 
hole  scars  which  are  likely  to  be  disfiguring  in  infected  cases. 

The  after-treatment  of  these  cases  is  of  great  importance.  The 
patients  or  friends  who  are  responsible  for  them  should  understand 
that  those  who  have  had  tuberculosis  in  any  form  are  susceptible  to 
further  trouble;  that  it  is  impossible  to  remove  every  lymphatic  gland 
from  the  neck  and  only  by  persevering  attention  to  general  hygienic 
living  can  they  expect  to  avoid  recurrence  of  the  disease  in  some  part 
of  the  body.  The  use  of  tuberculin  as  a  curative  measure  has  been 
lauded  by  a  number  of  writers  but  we  have  seen  quite  a  large  percentage 
of  failures  even  in  the  hands  of  the  advocates  of  this  treatment.  It  is 
possible  that  it  may  have  some  value  in  the  after-treatment  of  such 
cases.  The  importance  of  out-of-door  life,  out-of-door  sleeping  if 
possible,  keeping  nutrition  up  and  avoiding  overexertion  is  not  less 
important  for  a  cure  in  surgical  forms  of  tuberculosis  than  in  tuber-, 
culosis  of  the  lungs.  Reports  from  a  number  of  clinics  show  permanent 
cures  in  70  to  80  per  cent,  of  patients  who  have  had  the  radical  oper- 
ation, while  Demme's  report  on  692  patients  treated  at  the  Children's 
Hospital  in  Bern  by  constitutional  measures  without  surgery  shows 
nearly  30  per  cent,  of  cases  in  which  tuberculosis  of  the  lung,  intestine, 
brain  membranes  or  genito-urinary  tract  occurred,  without  mentioning 
the  rather  numerous  infections  of  bone  and  joints.  A  more  general 
knowledge  of  the  possible  grave  results  of  tuberculous  gland  infection 
will  undoubtedly  result  in  more  frequent  resort  to  early  radical 
operation. 

In  order  to  prevent  recurrence  of  tuberculous  glands  of  the  neck, 
it  is  important  to  determine  the  cause  and  to  remove  the  primary  focus 
VOL.  I — 45 


706  SURGERY  OF  THE  NECK 

of  infection.  In  a  very  large  proi)ortion  of  cases,  the  primary  infection 
can  be  found  in  the  tonsils  or  in  adenoids  contained  in  the  posterior 
nares.  It  frequently  happens  that  the  tonsils  became  infected  with 
tuberculosis  during,  or  after  some  acute  infectious  disease  like  measles, 
scarlatina  or  diphtheria,  the  infectious  disease  having  apparently  made 
it  possible  for  the  tubercle  bacilli  to  enter  the  tonsils  and  establish 
primary  tuberculosis  in  this  location.  Frequently  the  tonsils  are 
large  and  contain  numerous  tubercles;  at  other  times  they  may  be 
small  and  submerged  and  still  contain  one  or  more  tuberculous  areas. 
In  either  case  they  should  be  carefully  removed.  In  every  case  of 
tuberculous  lymph  nodes  in  the  cervical  region,  the  tonsils  and  the 
posterior  nasal  space  should  be  carefully  examined  for  tuberculosis, 
and  in  case  they  are  not  entirely  normal,  they  should  be  removed 
because  in  these  cases  the  tonsils  are  practically  always  shown  to  con- 
tain tuberculous  areas. 

When  the  tuberculous  lymph  nodes  are  situated  in  the  submaxillary 
region,  the  infectious  material  sometimes  enters  through  circumscribed 
areas  of  infection  around  carious  teeth.  In  all  such  instances  the 
patient  should  employ  a  competent  dentist  to  remove  all  dental 
sources  of  infection.  It  is  wtII  to  guard  against  the  further  introduc- 
tion of  tubercle  bacilli  in  these  cases  through  the  mouth  by  having 
these  patients  drink  raw  milk  from  cows  that  have  been  tuberculine 
tested,  or  if  this  is  not  possible,  to  have  all  milk  properly  sterilized. 

Funinculosis  or  Boils. — Diagnosis. — The  diagnosis  of  this  condition 
is  so  evident  that  no  space  need  be  devoted  to  it.  Treatment  is  of  some 
importance  because  if  not  successfully  handled  there  is  tendency  for 
the  infection  to  extend  under  the  deep  fascia  of  the  neck  and  cause  deep- 
seated  abscesses  which  may  be  of  considerable  gravity.  In  neglected 
cases  there  is  also  sometimes  development  of  carbuncle  or  of  multiple 
boils  which  reduce  the  health  and  strength  of  the  patient  decidedly. 

Treatment. — If  taken  when  in  the  incipient  stage,  boils  can  sometimes 
be  aborted  by  the  application  of  a  mild,  soothing  and  antiseptic  oint- 
ment. An  ointment  with  a  base  of  equal  parts  of  petrolatum  and  zinc 
oxide  ointment  and  10  grains  each  to  the  ounce  of  tar  and  salicylic  acid 
is  very  satisfactory  in  such  case.  If  a  necrotic  core  has  formed  in  a 
boil  of  considerable  size  it  can  ordinarily  be  handled  by  the  application 
of  a  heavy  moist  antiseptic  dressing;  boric  acid  or  a  weak  solution  of 
bichloride  of  mercury  (one  to  ten  or  twenty  thousand)  works  very 
satisfactorily.  This  is  really  an  application  of  Bier's  hyperemia  treat- 
ment. After  the  necrotic  core  has  formed  incision  is  rarely  necessary 
for  drainage.  To  prevent  infection  of  the  surrounding  hair  follicles, 
the  skin  should  be  thickly  smeared  with  sterile  ^•aseline  or  the  anti- 
septic ointment  which  has  been  mentioned.  In  case  of  multiple 
boils  the  general  condition  of  the  patient  needs  careful  attention.  An 
abundant  nourishing  diet  free  from  sugar,  and  tonics  are  important. 
The  urine  should  be  examined  to  make  sure  that  diabetes  is  not  present, 
and  when  it  is  present  suitable  medical  treatment  should  be  instituted 
as  well  as  the  surgical  treatment. 


DISEASES  OF  THE  NECK  707 

Carbuncle. — In  carbuncles  there  are  usually  a  number  of  necrotic 
cores  leading  down  to  the  site  of  deep  infection  which  is  located  under- 
neath the  deep  fascia  of  the  neck.  Energetic  treatment  should  be 
undertaken  early,  as  fatalities  haye  resulted  in  neglected  cases. 

Treatment. — The  carbuncle  should  be  freely  opened  either  with 
crucial  incision  or  the  thermocautery.  In  some  more  serious  cases 
excision  of  the  carbuncle  is  favored  by  some  surgeons.  The  application 
of  pure  carbolic  acid  to  the  cut  surfaces  may  be  of  some  value  in  pre- 
venting reinfection.  The  cavity  should  be  packed  lightly  with  anti- 
septic gauze  and  a  hea^^,'  moist  antiseptic  dressing  applied,  the  moisture 
being  retained  by  oiled  muslin  or  silk.  Attention  to  the  general  health 
of  the  patient  is  even  more  important  than  in  furunculosis.  In  cases 
which  do  not  readily  yield  to  treatment  an  autogenous  vaccine  might 
be  of  some  value.  There  is  considerable  difference  of  opinion  as  to  the 
value  of  the  stock  staphylococcus  vaccines  which  are  on  the  market, 
the  houses  which  prepare  these  vaccines  naturally  lauding  their  use 
very  highly.  In  case  an  extensive  raw  surface  is  left  from  sloughing 
with  a  carbuncle,  skin  grafting  is  sometimes  of  value.  Small  grafts 
scattered  over  the  surface  do  not  prevent  free  escape  of  wound  secretion 
and  add  a  good  deal  to  the  rapidity  of  healing. 

Abscesses. — Abscesses,  cellulitis  of  the  neck  and  deeply  located 
phlegmonous  processes  arise  from  direct  infections  from  wounds  of  the 
skin  or  mucous  membranes,  from  extension  of  inflammatory  processes 
in  neighboring  organs,  for  example  peritonsillar  abscesses  and  mastoid 
abscesses,  or  directly  from  the  blood  stream.  In  occasional  rare  cases 
an  abscess  apparently  arises  from  metastasis  in  cases  of  pyemia.  The 
diagnosis  of  abscess  arising  from  continuity  is  usually  not  difficult. 
Where  such  a  direct  extension  is  not  present  the  diagnosis  may  be 
considerably  more  difficult.  The  general  symptoms  of  acute  inflam- 
mation, considerable  degree  of  fever  beginning  with  or  without  a  chill, 
increased  number  of  pohTnorphonuclear  leukocytes,  swelling,  deep- 
seated  pain  and  tenderness  make  the  diagnosis  reasonably  clear,  how- 
ever. Fluctuation  does  not  appear  until  the  abscess  has  worked  toward 
the  surface. 

Deep-seated  inflammation  of  the  connective  tissue  of  the  upper  part 
of  the  neck  in  the  region  of  the  salivary  glands  occasionally  occurs. 

Because  of  the  deep  location,  severe  pressure  symptoms  appear 
early  and  a  fatal  outcome  frequently  occurs  unless  the  condition  is 
promptly  recognized  and  treated.  This  condition  was  first  described 
by  Ludwig  in  1836  and  is  frequently  spoken  of  as  Liidwig's  angina.  It 
frequently  begins  with  a  chill  followed  by  high  fever  and  great  pros- 
tration. Difficulty  in  swallowing  and  breathing  develop  early,  as  well 
as  a  diffuse,  firm  swelling  in  the  submaxillary  region  which  is  not 
sharply  outlined.  Therais  a  good  deal  of  tenderness  on  pressure.  The 
skin  is  at  first  unchanged,  but  as  the  inflammation  develops  edema 
appears.  The  patient  has  difficulty  in  opening  his  mouth;  there  is  a 
profuse  flow  of  saliva  and  the  breath  is  extremely  fetid.  The  presence 
of  such  inflammatory  swelling  m  the  suprahyoid  region  should  lead 


708  .  SURGERY  OF  THE  NECK 

to  a  suspicion  of  this  trouble.  Differential  diagnosis  from  an  inflam- 
matory process  extending  from  the  floor  of  the  mouth  or  periostitis  of 
the  lower  jaw  may  sometimes  have  to  be  considered.  The  grave 
symptoms  and  rapid  course  of  the  disease  ordinarily  leave  little  doubt 
as  to  the  diagnosis.  If  neglected,  a  fatal  outcome  is  likely  to  result 
within  a  few  days  from  general  sepsis  or  in  certain  cases  from  edema 
of  the  larynx.  In  less  severe  cases  a  localized  abscess  may  form  with 
discharge  of  pus. 

Treatment. — The  deeper  layers  of  fascia  and  aponeuroses  determine 
the  location  and  spread  of  collections  of  pus  and  hence  influence  the 
placing  of  incisions  and  drainage.  Much  controversy  has  arisen  with 
regard  to  the  anatomy  of  the  deep  fascia  of  the  neck  which  it  is  not 
necessary  to  enter  into  at  this  time.  If  a  diagnosis  of  deep-seated 
infection  can  be  made  with  reasonable  certainty,  early  drainage 
and  free  drainage  are  the  most  important  considerations.  In  many 
cases  the  method  suggested  by  Hilton  of  making  a  skin  incision  and 
then  boring  deeply  into  the  tissues  with  blunt  pointed  forceps  which  are 
opened  up  when  the  pus  cavity  is  located  will  prove  of  value.  The 
surface  incision  may  be  enlarged  if  necessary  and  should  be  placed  in 
the  best  location  to  drain  the  infection  without  special  regard  for  other 
considerations.  In  avoiding  important  structures  multiple  incisions 
are  frequently  of  use  to  freely  drain  deep-seated  abscesses.  Cigarette 
drains  may  be  used  or  more  frequently  the  wound  is  lightly  packed  with 
drainage  strips.  The  important  point  is  to  provide  free  exit  for  the  pus 
and  unless  this  is  accomplished  there  is  grave  danger  of  sepsis,  of  exten- 
sion of  the  process  into  mediastinum,  or  of  breaking  through  into  the 
trachea  or  esophagus,  and  in  rare  instances  there  has  been  erosion  of 
the  walls  of  one  of  the  greater  bloodvessels  of  the  neck.  The  general 
treatment  of  the  patient  should  not  be  neglected.  With  this  and  free 
drainage  there  is  usually  no  necessity  for  considering  such  special 
measures  as  the  use  of  vaccines  or  special  hjqDeremia  devices. 

Cervical  Rib. — Cervical  rib  in  and  of  itself  may  not  cause  any 
trouble  and  frequently  is  discovered  accidentally.  Since  the  publi- 
cation by  Keen  in  1907  reporting  43  cases  the  attention  of  American 
surgeons  has  been  attracted  to  the  subject  and  cases  have  been  diag- 
nosed more  frequently,  however.  S^^nptoms  when  present,  concern 
usually  the  nerve  trunks  of  the  brachial  plexus  or  the  circulation  of 
the  subclavian  artery.  The  sensory  nerves  are  almost  exclusively 
affected  so  that  frequently  the  first  symptom  is  severe  neuralgic  pain 
in  the  arm.  In  less  extreme  cases  there  is  numbness,  crawling  or 
prickling  sensations,  and  frequently  a  feeling  of  weakness  or  of  the  arm 
going  to  sleep.  Usually  there  are  no  motor  disturbances,  paralysis 
having  not  been  reported  up  to  this  date.  The  muscles  respond  less 
freely  to  electrical  stimulus  and  in  certain  case»  there  has  been  atrophy 
of  the  small  muscles  of  the  hand.  Hoarseness  had  been  reported  from 
pressure  on  the  recurrent  nerve,  and  Hunt  has  reported  a  case  in  which 
there  was  a  chronic  cramp-like  condition  of  the  diaphragm,  which  was 
relieved  by  the  removal  of  a  cervical  rib  from  the  left  side.    The  cir- 


DISEASES  OF  THE  NECK 


709 


culatory  symptoms  are  less  troublesome  as  a  rule  than  those  referred  to 
the  brachial  plexus.  There  is  sometimes  weakness  of  the  radial  pulse, 
paleness  of  the  hands  and  arms,  and  possibly  lowered  surface  tempera- 
ture. In  certain  cases  thrombosis  has  been  attributed  to  the  presence 
of  cervical  rib,  also  the  development  of  aneurysm.  As  a  rule  throm- 
bosis is  developed  so  slowly  that  collateral  circulation  has  been  well 
established  and  symptoms  have  not  been  very  noticeable.  The  sub- 
clavian artery  passes  over  a  cervical  rib  in  the  majority  of  cases  and 
consequently  is  more  superficial  than  usual.  In  some  cases  the  rib  is 
free  and  slightly  movable;  in  other  cases  it  is  attached  by  bony  or 
fibrous  union  to  the  first  rib;  while  in  other  cases  there  is  a  true  costal 
cartilage  attached  to  the  sternum.  Anatomists  have  found  the  condi- 
tion more  usually  bilateral.  As  a  rule  the  rib  arises  from  the  seventh 
cervical  vertebra,  but  in  rare  instances  a  sixth  cervical  rib  has  been 
observed.     The  differential  diagnosis  from  neuritis,  neuralgia,  rheu- 


^-- 

ry 

Rifff/t 

:^M 

s                      Ij         left 

J, 

v// 

CR 

RI 

M 

^J       CR 
^         Rf 

[                               RR 

RM 

9^^^^^^l 

1        ^            'M 

L    ,. Jim     .S 

Fig.  495. — Bilateral  cervical  ribs,     (de  Quervain.) 


matism  or  other  painful  conditions  affecting  the  upper  extremity  is 
usually  not  difficult.  In  these  conditions  circulatory  difficulties  are 
not  present  nor  is  there  any  noticeable  prominence.  The  differential 
diagnosis  from  tumors  in  the  supraclavicular  region,  particularly 
tuberculous  enlargment  of  the  lymphatic  glands,  is  also  usually  not 
difficult.  The  swelling  of  cervical  rib  is  very  much  harder  and  not 
movable.  Pain  and  circulatory  disturbances  are  apt  to  be  more 
constant  symptoms  in  cervical  rib  than  in  tumors  of  this  locality. 
Exostosis  of  the  first  rib  sometimes  gives  rise  to  somewhat  similar 
symptoms,  but  there  is  more  likely  to  be  pressure  on  the  vein  with 
edema  of  the  arm  than  is  the  case  with  cervical  rib.  In  any  doubtful 
cases  a  positive  diagnosis  could  be  made  by  suitable  a:-ray  examination. 
Treatment. — Treatment  consists  in  the  removal  of  the  cause;  the 
resection  of  the  prominent  rib.  An  incision  may  be  made  placed 
along  the  posterior  border  of  the  sternomastoid  muscle,  or  better. 


710  SURGERY  OF  THE  NECK 

within  the  hair-line  and  joined  with  one  parallel  to  the  elavicle.  The 
danger  of  injury  to  the  pleura,  the  brachial  plexus  and  subclavian  ves- 
sels should  be  kept  in  mind.  The  brachial  plexus  is  usually  retracted 
toward  the  median  side,  undue  tension  of  the  ner\-e  trunks  being  avoided 
with  great  care.  The  subclavian  artery  and  vein  are  drawn  forward. 
The  scalenus  muscle  is  carefully  divided  near  its  insertion  and  all  other 
attached  muscles  are  separated.  The  rib  should  not  be  removed  sub- 
periosteally  as  in  that  case  recurrence  is  likely  to  follow.  The  pleura 
has  been  frequently  torn  in  such  operations  but  no  serious  results  have 
followed,  and  if  a  gauze  pad  is  quickly  packed  into  the  opening, 
pneumothorax  does  not  usually  result.  The  bone  may  be  di\ided  by 
passing  a  Gigli  saw  underneath  it  using  care  to  avoid  other  important 
structures  in  the  neighborhood.  Or  it  may  be  cut  with  rib  shears  if 
this  is  found  more  convenient,  but  injury  to  the  important  surround- 
ing structures  is  perhaps  less  easily  avoided.  The  wounrl  closure  and 
dressings  require  no  special  comment.  The  results  of  the  operation 
have  been  highly  satisfactory  in  most  cases. 

TUMORS  OF  THE  NECK. 

Cysts  of  the  Neck. — Diagnosis. — The  various  cysts  of  the  neck  have 
so  many  features  in  common  that  they  may  be  considered  most  con- 
veniently as  a  group-  In  form  they  are  usually  rounded.  The  size 
varies  within  the  widest  limits,  but  in  general  branchial,  thyreoglossal 
and  bursal  cysts  are  relatively  small  while  lymphatic  and  blood  cysts 
are  large.  Even  when  tense  with  fluid  they  have  an  elastic  feel  and 
when  the  fluid  is  less  tense  there  is  sometimes  definite  fluctuation. 
These  characteristics  as  to  form,  consistency  and  fluctuation  are  shared 
by  certain  lipomas,  also  sometimes  by  soft  sarcomas,  although  the 
sarcomas  are  more  frequently  nodular  and  of  firmer  consistency.  Cer- 
tain aneurysms  may  also  have  some  of  these  characteristics  but  could 
be  distinguished  by  expansile  pulsation.  Differing  from  the  softer 
malignant  tumors,  the  growth  of  cysts  is  usually  slow;  is  not  accom- 
panied by  cachexia;  and  there  is  not  metastatic  involvement  of 
distant  parts  of  the  body.  From  deeper  seated  abscesses,  whether 
originating  from  caries  of  the  cervical  spine  or  from  breaking  down  of 
the  glands  of  the  neck,  the  cysts  can  usually  be  distinguished  by  a 
history  of  inflammation,  more  general  systemic  disturbance,  and  usually 
much  shorter  duration.  Exploratory  puncture  with  an  aspirating 
needle  readily  determines  the  character  of  the  growth  in  the  majority 
of  cases. 

The  differential  diagnosis  of  the  cysts  one  from  another  is  sometimes 
difficult  or  impossible,  but  in  many  cases  the  characteristic  location  is 
the  key  to  the  situation.  For  convenience  the  cysts  may  be  divided 
into  those  caused  by  abnormal  embryonic  development;  the  retention 
cysts;  cysts  having  their  origin  from  bursse  about  the  larynx  or  hyoid 
bone;  the  blood  cysts;  lymphatic  cysts;  and  those  of  parasitic  origin, 
usuallv  echinococcus. 


TUMORS  OF  THE  NECK 


711 


The  cysts  arising  from  irregularities  in  development  are  sometimes 
further  divided  according  to  the  character  of  their  contents  into  serous, 
mucous  and  dermoid  cysts.  The  location  of  these  cysts  is  more  or  less 
characteristic  and  usually  a  chief  factor  in  the  diagnosis  of  the  variety 
present.  Many  median-line  growths  have  their  origin  along  the  course 
of  the  thyreoglossal  duct,  which  in  the  early  stages  of  embryonic 
development  extends  from  the  middle  lobe  of  the  thyroid  to  the  base  of 
the  tongue.  As  a  rule  the  thyreoglossal  duct  entirely  disappears, 
except  as  a  fibrous  band,  at  about  the  fifth  week  of  intra-  uterine  develop- 
ment, but  in  certain  cases  that  portion  above  the  hyoid  bone  persists 
and  is  spoken  of  as  the  ductus  lingualis.  More  frequently  the  portion 
below  the  hyoid  bone  persists,  sometimes  forming  the  so-called  pyram- 
idal lobe  and  in  other  cases  slowly  enlarging  to  form  a  cyst,  which 
because  of  its  conspicuous  location  is  usually  removed  while  of 
small  or  moderate  size.  These  cysts 
are  seen  in  children  and  in  early  adult 
life,  occasionally  among  older  people. 
The  contents  are  usually  colorless 
mucous,  or  thin  gelatinous  material. 
Those  cysts  having  their  origin  above 
the  hyoid  bone  are  lined  with  flat- 
tened entodermal  epithelium,  while 
those  below  the  hyoid  bone  are  lined 
with  cylindrical,  sometimes  ciliated, 
epithelium. 

Teratoma  or  Dermoid  Cysts  of  the 
Neck.  ■ —  These  growths  are  usually 
located  on  the  anterior  and  lateral 
aspect  of  the  neck  corresponding 
closely  in  position  to  the  tumors  of 
the  thyroid  and  also  moving  with 
swallowing.  The  surrounding  tissues 
are  not  involved  unless  there  has  been 

some  secondary  inflammation  and  they  are  usually  freely  movable, 
painless,  slow  growing,  and  without  symptoms  until  they  enlarge  to 
such  an  extent  as  to  press  upon  the  air  passages.  A  positive  diagnosis 
before  removal  is  usually  impossible.  At  the  time  of  the  operation  the 
contents  of  the  cyst  indicate  its  character.  The  presence  of  sebaceous 
material,  hairs  and  other  of  the  usual  contents  of  dermoid  cysts  is 
characteristic.  While  the  tumors  are  ordinarily  benign  they  sometimes 
undergo  malignant  change,  which  is  frequently  sarcomatous,  and  they 
are  usually  readily  removed  if  taken  before  the  growth  has  reached 
considerable  size  and  has  not  involved  surrounding  tissues. 

The  lateral  embryonic  remnant  cysts  have  their  origin  in  imperfect 
closure  of  the  gill  slits  or  branchial  clefts  and  are  sometimes  known  as 
branchial  cleft  cysts.  Like  the  lateral  fistulse  of  the  neck  they  some- 
times have  their  origin  in  a  persistent  thyreopharyngeal  duct.  The  con- 
tents of  these  cysts  may  be  serous,  mucous,  gelatinous,  or  may  resemble 


Fig.  496. — ^Congenital  median  cyst 
of  the  neck,      (de  Quervain.) 


12 


SURGERY  OF  THE  NECK 


the  contents  of  a  sebaceous  cyst,  sometimes  containing  cell  detritus, 
epithelium  and  frequently  cholesterin  crystals.  The  Iming  membrane 
of  these  lateral  cysts  as  well  as  the  median  thyreoglossal  rest  cysts  is 
epithelial. 

The  sebaceous  retention  cysts  of  the  skin  of  the  neck  are  so  common 
and  usually  so  easily  distinguished  that  it  is  scarcely  necessary  to  go 
into  the  differential  diagnosis  in  detail.  Their  growth  is  slow  and 
symptomless ;  they  are  located  in  the  skin  and  do  not  move  on  swallow- 
ing as  do  the  branchial  cleft  or  thyreoglossal  duct  cysts;  their  contents 
are  characteristic  sebaceous  material. 

The  bursal  cysts  arising  from  the  burste  about  the  larynx  and  hyoid 
bone  contain  mucus;  move  with  swallowing;  and  are  usually  of  small 
size  and  slow  development.  The  bursa  between  th^Tcohyoid  ligament 
and  the  body  of  the  hyoid  bone  is  perhaps  most  commonly  affected,  and 

this  is  known  sometimes  as  the  sub- 
hyoid bursal  cyst.  In  adults  there 
is  usually  a  bursa  over  the  Adam's 
apple,  sometimes  called  the  ante- 
thyroid  or  prethyroid  bursa.  This 
is  not  constant;  is  not  found  with 
children  as  a  rule,  which  together 
with  its  location  might  help  to  dis- 
tinguish it  from  the  thyreoglossal 
cysts.  A  bursa  is  occasionally  present 
between  the  posterior  insertion  of 
the  geniohyoid  and  genioglossal 
muscles,  known  as  the  suprahyoid 
bursa,  which  in  rare  instances  gives 
rise  to  cyst  formation.  Injury  or 
infection  (formerly  spoken  of  as 
rheumatic)  or  unknown  causes  some- 
times give  rise  to  accumulation  of 
fluid  in  these  bursse.  The  most  com- 
mon are  the  subhyoid  bursal  cysts. 
They  are  usually  small,  for  the  most  part  painless,  and  are  removed 
because  of  appearance  only. 

The  blood  cysts  Spannaus  divides  into  sLx  classes:  (1)  those  arising 
from  arrested  fetal  development;  (2)  those  arising  in  the  brachial 
cleft  cysts;  (3)  from  partial  ectasis  of  veins;  (4)  from  cavernous 
angiomas;  (5)  from  lymphangiomas;  (6)  from  malformations  of  the 
lymphatic  glands.  They  may  be  congenital  or  may  appear  at  almost 
any  age  up  to  fifty.  They  vary  in  size  from  that  of  a  nut  to  that  of  a 
child's  head;  frequently  occupy  an  entire  side  of  the  neck;  are  some- 
times located  under  the  sternomastoid  muscle;  and  in  a  few  cases 
extend  into  the  axilla  or  thorax.  The  tension  of  the  fluid  contents  is 
usually  increased  by  coughing  or  other  expiratory  pressure  and  serious 
symptoms  frequently  arise  from  pressure  on  neighboring  organs.  The 
growth  is  sometimes  rapid,  sometimes  slow,  and  it  may  remain  station- 


FiG.   497. — Congenital    cystic   l\iiipliaii- 
gioma  of  the  neck,     (de  Quervain.) 


TUMORS  OF   THE  NECK  713 

ary  for  a  long  time.  Aspiration  of  the  cyst  contents  will  reveal  its 
true  character. 

The  lymphatic  cysts  of  the  neck,  sometimes  spoken  of  as  hygroma 
cysticmn  colli  are  usually  congenital  or  appear  in  the  first  year  of  life. 
They  are  usually  located  in  the  deep-lying  connective  tissue  or  in  the 
subcutaneous  fat  and  are  very  frequently  found  along  the  great  vessel 
sheaths.  Dowd  has  collected  91  cases  from  literature  and  considers 
them  one  of  the  infrequent  forms  of  neck  tumor.  In  certain  cases  the 
growth  is  rapid,  pressing  between  all  the  organs  of  the  neck,  sometimes 
extending  far  doTVTi  mto  the  mediastiniun.  There  is  usually  no  definite 
•limiting  capsule,  in  distinction  to  embryonic  rest,  retention  and  para- 
sitic cysts  of  the  neck.  Microscopically  these  cysts  are  lined  with  endo- 
theliiun,  and  contain  greatly  dilated  hinph  vessels  and  lymph  spaces 
with  many  outpocketmgs.  The  contents  may  be  clear  and  serous, 
bro-R-nish  if  stained  with  blood,  or  a  milky,  cloudy  fluid.  The  growth  is 
apt  to  be  slow  but  steady,  and  pressure  symptoms  are  common. 

Echinococcus  cysts  are  among  the  rarest  of  the  tumors  of  the  neck, 
only  26  cases  having  been  collected  from  the  entire  surgical  literature 
by  Guterbock  in  1893.  In  the  majority  of  cases  they  are  located  deeply 
along  the  sheaths  of  the  great  bloodvessels  underneath  the  sterno- 
mastoid  muscle.  The  growth  is  usually  slow  and  in  certain  cases  they 
reach  enormous  size  even  invading  the  thoracic  cavity.  Cases  are  on 
record  in  which  fatal  hemorrhage  has  resulted  because  of  erosion  of 
the  great  bloodvessels.  Diagnosis  in  many  cases  is  absolutely  impos- 
sible without  exploratory  incision.  In  size,  appearance,  location  and 
growth  the  cysts  closely  resemble  the  blood  and  lymphatic  cysts  of  the 
neck.  Even  exploratory  aspiration  might  not  give  the  characteristic 
booklets  and  there  is  nothing  else  in  the  contents  of  the  cysts  to  differ- 
entiate them  from  certain  of  the  blood  or  lymphatic  cysts.  The 
hydatid  thrill  which  is  spoken  of  in  connection  with  the  diagnosis 
of  the  echinococcus  cysts  in  other  parts  of  the  body  is  usually  absent. 

Treatment. — Three  forms  of  treatment  have  been  suggested  for  the 
cure  of  cj'sts  of  the  neck : 

1.  Aspiration  and  the  injection  of  some  irritating  solution  to  destroy 
the  secreting  membrane.  This  method  is  very  uncertain  in  its  result, 
usually  not  giving  a  cure,  and  there  is  also  danger  of  the  injected 
irritant's  entering  communicating  vessels  or  lymphatics.  In  the 
pre-antiseptic  days  it  was  widely  used,  but  at  present  there  would  be 
few  cases  in  which  it  would  seem  to  be  indicated. 

2.  Incision  and  packmg  of  the  cyst  cavity  may  be  used,  but  it  also 
is  uncertam  in  results,  the  cure  requiring  prolonged  treatment,  and 
there  is  risk  to  life  from  infection  and  sepsis  even  with  the  most  careful 
antiseptic  methods.  This  method  might  have  to  be  employed  in  cases 
where  the  large  vessels  were  eroded  or  in  case  of  unusual  difficulty  in 
removing  the  cyst  wall  because  of  its  close  relation  to  important  blood- 
vessels, nerves  or  other  important  structures  of  the  neck. 

3.  Complete  excision  of  the  entire  cyst  wall  is  the  method  of  choice 
in  the  vast  majority  of  cases.    In  general  the  methods  suggested  under 


"14 


SURGERY  OF  THE  XECK 


the  heading  "Operations  of  the  Xeck"  would  apply  to  the  treatment 
of  these  neek  tumors.  In  a  large  pereentage  of  small  cysts  superficially 
located,  it  is  j)ossible  to  excise  with  local  anesthesia.  If  rupture  of  the 
cyst  wall  can  be  avoided  until  the  dissection  is  complete,  or  nearly  so, 
it  will  be  of  great  help  in  remo\ing  the  entire  secreting  membrane,  but 
this  is  frequently  difficult  or  entirely  impossible.  In  most  cases  the  chief 
difficulty  is  in  identifying  the  lining  membrane  of  the  cyst,  and,  as  an 
aid  to  the  complete  removal  of  the  cyst  wall,  some  staining  fluid  may  be 
injected  into  the  cyst  cavity.  Methylene  blue  is>  perhaps  most  fre- 
quently used.  A  good  a'-ray  might 
be  of  some  help  in  the  operative 
removal  of  some  of  these  cysts, 
especially  those  of  large  size.  Re- 
mo\al  of  the  larger  cysts  in  the  close 
neighborhood  of  the  great  blood- 
vessels and  nerve  trunks  is  often 
accompanied  by  a  great  deal  of  diffi- 
culty and  danger.  In  some  of  these 
cases  it  would  be  much  safer  to 
leave  a  portion  of  the  lining  mem- 
brane of  the  cyst  and  destroy  the 
secreting  surface,  if  possible,  by  an 
application  of  pure  carbolic  acid  or 
some  other  irritating  chemical. 
Such  treatment  would  be  prefer- 
able to  incision  and  packing  except 
in  case  of  dangerous  hemorrhage 
where  an  eroded  vessel  communi- 
cated with  the  cavity. 

As  a  rule  no  method  of  treat- 
ment except  complete  excision  of 
the  entire  secreting  surface  will  re- 
sult in  a  permanent  cure. 

Solid  Tumors  of  the  Neck. — For 
convenience  in  discussion  the  solid 
tumors  of  the  neck  are  grouped  to- 
gether as  they  have  many  features 
in  common  as  to  diagnosis  and 
treatment.  Benign  and  malignant  tumors  have  to  be  considered.  The 
benign  tumors  conform  in  type  to  the  fully  formed  connective  tissues 
and  include  those  arising  from  the  fibrous  structures  of  the  neck,  from 
the  fatty  tissue  of  the  neck,  the  nerves,  great  bloodvessels  or  cartilage. 
All  the  benign  solid  tumors  of  the  neck  are  relatively  slow  in  growth. 
They  do  not  tend  to  in^■olve  surroimding  structures  or  to  produce 
metastases.  They  do  not  as  a  rule  produce  general  symptoms,  espec- 
ially cachexia,  as  do  the  malignant  growths,  and  the  location  of  some 
benign  tumors  is  characteristic,  \\hile  not  nearly  all  of  the  benign 
tumors  are  encapsulated,  encapsulation  is  more  common  than  with 


Fig.  498.  —  Oculo-pupiUary  syn- 
drome iDejerine-Klumpke  syndrome). 
Sinking  in  of  the  eye;  constriction  of 
the  palpebral  fissure;  mycosis.  From 
pressure  on  the  first  dorsal  nerve  root 
or  the  sjTDpathetic  near  there. 


TUMORS  OF  THE  NECK  715 

malignant  growths  and,  when  present,  is  generally  an  indication  of  the 
benign  nature  of  the  tumor.  Pressure  symptoms  develop  late  because 
of  the  slow  growth  of  these  tumors  and  the  adaptation  to  their  presence. 
Difficulty  in  breathing  or  swallowing,  and  hoarseness  or  loss  of  voice 
are,  however,  sometimes  present  in  case  of  the  deeply  located  benign 
tumors.  The  differential  diagnosis  of  the  various  forms  of  benign 
tumors  of  the  neck  is  not  difficult  as  a  rule. 

Fibromas. — These  are  among  the  more  common  tumors  of  the  neck 
and  may  be  located  either  superficially  or  deeply.  Because  a  number  of 
these  tumors  contain  a  varying  proportion  of  nervous  tissue  or  vessels, 
they  are  sometimes  classed  as  neurofibromas  and  angiofibromas,  but 
if  the  nerve  or  vessel  elements  are  in  large  amount  they  more  properly 
come  under  the  heading  of  neuromas  and  angiomas.  The  deep-seated 
fibromas  of  the  neck  sometimes  take  their  origin  from  the  aponeuroses 
of  the  muscles,  sometimes  from  the  periosteum  of  the  vertebrae. 
These  deep-seated  fibromas  are  much  more  common  in  the  posterior 
part  of  the  neck,  but  may  be  found  about  the  anterior  part  of  the 
neck.  In  certain  cases  they  take  their  origin  from  the  fibrous  tissue 
forming  the  sheath  of  the  great  bloodvessels  and  nerves.  In  such 
deeply-seated  fibromas  of  the  anterior  surface  of  the  neck,  pressure 
symptoms  are  apt  to  develop  relatively  early.  The  diagnosis  from  the 
other  benign  tumors  is  usually  easy  because  of  the  firmer  consistency, 
while  slower  growth  distinguishes  them  from  the  sarcomas. 

Lipoma. — These  tumors  are  among  the  most  common  solid  tumors  of 
the  neck  and  they  occur  at  every  age.  Depending  upon  the  presence  or 
absence  of  a  limiting  capsule  they  are  sometimes  classed  as  circum- 
scribed or  diffuse  lipomas;  according  to  location  as  subcutaneous  or 
subfacial.  A  diagnostic  point  of  much  value  when  present  is  the 
dimpling  of  the  skin  when  the  tumor  is  picked  up.  Lobulation  is  also 
somewhat  characteristic  of  the  fatty  tumors.  These  symptoms  are  not 
usually  present  with  the  deeply  seated  subfacial  lipomas.  The  soft 
fluctuating  feel  might  give  difficulty  in  distinguishing  the  lipomas  from 
the  cysts  or  abscesses  of  the  neck. ..  Cystic  goiter  moves  on  swallowing, 
as  do  the  cysts  i  i  the  neighborhood  of  the  larynx  whether  taking  their 
origin  from  the  bursse  about  the  larynx  or  from  the  thyreoglossal  duct. 
The  abscesses  would  ordinarily  have  a  history  of  inflammatory  symp- 
toms and  much  more  rapid  development.  The  deeply  seated  subfacial 
lipomas  may  extend  between  the  greater  vessels  of  the  neck  and  sur- 
round the  trachea  and  esophagus  in  somewhat  similar  way  to  sarcoma. 
At  operation,  however,  the  attachments  are  usually  readily  separated 
by  blunt  dissection,  there  being  no  definite  involvement  of  these 
tissues  as  with  the  malignant  growths.  A  diffuse  lipoma  may  exist 
in  any  part  of  the  neck  but  occurs  most  commonly  under  the  chin 
the  so-called  double  chin,  but  diffuse  masses  of  fat  may  appear  at 
almost  any  place  on  the  neck.  Lobulation  and  dimpling  of  the  skin 
are  less  common  than  with  the  ordinary  subcutaneous  lipoma. 

Dissecting  Lipoma. — This  form  of  lipoma  usually  begins  in  the  fatty 
tissue  overlying  the  trapezius  muscle.     It  is  usually  recognized  at 


716 


SURGERY  OF  THE  NECK 


first  upon  the  posterior  surface  of  the  neck  in  the  middle  Hne  and 
advances  symmetrically  to  the  right  and  to  the  left  following  the 
fascia  of  the  muscles  of  the  neck  and  passing  into  the  spaces  between 
the  various  muscles.  It  may  attain  a  thickness  of  10  cm.  at  the  point 
of  its  starting,  tapering  off  to  the  right  and  to  the  left.  As  it  passes 
around  the  front  of  the  neck,  it  may  follow  the  fascia  covering  the, 
anterior  muscles  of  the  neck  and  pass  in  between  these  muscles.     It 

may  become  so  large  and  cumbersome 
as  to  interfere  greatly  with  the  move- 
ment of  th^  head  and  with  respiration. 

Treatment. — It  is  usually  best  to  re- 
move the  tumor  in  two  sittings,  because 
if  the  entire  tumor  is  removed  at  one  sit- 
ting in  advanced  cases,  it  is  very  difficult 
for  the  patient  to  lie  in  bed  because  of 
the  pain  caused  by  the  extensive  wound. 
If  removed  in  two  sittings,  the  patient 
can  lie  on  the  side  opposite  to  which  the 
first  portion  of  the  tumor  has  been  re- 
moved until  the  wound  has  healed,  and 
later  he  may  lie  on  the  side  first  operated. 
Angioma.  —  There    are    two    distinct 
classes  of  tumors  arising  from  the  blood- 
vessels of  the  neck.     The  ordinary  simple 
angioma,  nevus  or  birthmark,   and  the 
extensive   cavernous    angioma    contain- 
ing large  blood  spaces.    The  port  wine 
discoloration  of  the  skin  is  quite  char- 
acteristic and  ordinarily  there  is  no  difficulty  in  the  diagnosis  of  the 
simple  nevus.     The  cavernous  angioma  may  be  either  superficial  or 
deeply  seated.    They  occur  rarely  in  young  children,  most  commonly 
with  grown  people,  and  are  one  of  the  less  common  tumors  of  the  neck. 
In  certain  cases  they  are  surrounded  by  a  definite  capsule,  but  some- 
what more  frequently,  probably,  there  is  no  definite  limitation  to  the 
growth.    Theh  connection  is  usually  with  the  veins  although  occasion- 
ally with  the  smaller  arteries.    A  somewhat  characteristic  symptom  of 
these  tumors  is  the  increase  in  size  on  coughing,  sneezing  or  any  other 
expiratory  effort.    It  is  also  usually  possible  to  decrease  the  size  of  these 
tumors  by  firm,  continued  pressure,  the  mass  reappearing  when  the 
pressure  is  removed.    With  the  deeply  seated  angiomas  the  diagnosis 
may  be  extremely  difficult  and  in  certain  cases  impossible.    While  the 
growth  is  usually  slow  it  may  be  rapid  and  in  certain  cases  gives  rise  to 
very  distressing  symptoms  because  of  pressure  on  the  trachea  or  larynx. 
Neuroma.— The  tumors  of  nerve  origin  arise  either  from  the  super- 
ficial nerve  endings  or  from  the  deeply  seated  nerves  of  the  neck, 
especially   the   vagus   or    pneumogastric.     Those   arising   from    the 
superficial  nerve  endings  are  among  the  most  common  tumors  of  the 
neck.    There  is  usually  a  large  admixture  of  fibrous  tissue  and  they 


Fig.  499. — Diffuse  dissecting 
lipoma  of  the  neck,  (de  Quer- 
vain.) 


TUMORS  OF  THE  NECK  111 

are  sometimes  classed  among  the  fibromas.  In  case  of  the  common 
fibroma  molluscum  large  areas  of  skin  and  subcutaneous  tissue 
may  be  involved.  The  skin  is  frequently  very  much  thickened  and 
pigmented,  and  there  may  be  an  outgrowth  of  hair.  The  appearance 
of  these  tumors  is  usually  so  characteristic  that  there  is  very  little 
difficulty  ui  diagnosis.  Tumors  taking  their  origin  from  the  deep- 
lying  nerves  of  the  neck  are  among  the  rarest  of  the  neck  tumors.  In 
certain  cases  the  diagnosis  would  be  absolutely  impossible.  A  char- 
acteristic symptom  of  nerve  involvement,  when  present,  is  the  hoarse- 
ness or  huskmess  caused  by  the  involvement  of  the  pneumogastric 
nerve,  and  in  certain  cases  there  is  difficulty  in  the  heart's  action. 

Enchondromas. — These  are  among  the  very  rarest  tumors  of  the  neck, 
only  two  or  three  cases  having  been  reported  up  to  this  time.  It  is 
supposed  that  they  take  their  origin  from  remnants  of  entodermal 
tissue  in  the  neighborhood  of  the  branchial  clefts.  The  hardness  of  the 
growth  and  its  characteristic  location  might  be  of  some  help  in  the 
diagnosis  of  such  cases. 

Treatment  of  the  Solid  Benign  Tumors  of  the  Neck. — Excision  of 
the  growth  in  accordance  with  the  general  prmciples  of  surgery 
of  this  locality  is  indicated  in  the  majority  of  cases.  Usually  no 
special  difficulty  is  encountered.  The  advanced  fibromas  are  some- 
times adherent  to  the  great  vessels,  requiring  ligation  of  the  vessels 
before  excision.  The  superficial  encapsulated  lipomas  are  usually 
readily  excised,  and  even  the  deeply  seated  lipomas  offer  no  unusual 
difiiculties  in  enucleation  as  a  rule,  the  outgrowth  in  the  neighbor- 
hood of  great  vessels  or  other  important  deep  structures  being  easily 
separated  by  blunt  dissection.  Because  of  the  extent  of  the  growth 
and  the  poor  vitality  of  fatty  tissue  there  is  slightly  greater 
danger  of  infection  after  removal  of  extensive  diffuse  lipomas.  Care 
should  be  taken  to  secure  all  larger  bloodvessels  in  the  neighborhood 
of  the  fatty  timiors,  and  in  extensive  gro^\i:hs  drainage  for  twenty-four 
hours  is  desirable  because  of  a  tendency  to  ooze.  Loewenthal  has 
suggested  the  treatment  of  diffuse  fatty  tumors  by  the  injection  of  ether 
and  alcohol.  He  reports  a  case  in  which  a  tumor  was  cured  by  forty- two 
mjections,  but  we  are  not  aware  that  his  suggestion  as  regards  the  treat- 
ment of  these  tumors  has  been  taken  up  elsewhere.  The  simple  birth- 
marks are  perhaps  most  conveniently  treated  by  carbon  dioxide  snow 
in  suitable  cases.  Some  prefer  the  use  of  the  electric  needle  or  a  fine 
actual  cautery.  Excision  and  suture  might  be  used  in  some  less  exten- 
sive cases  and  excision  and  skui  graftmg  has  been  used  in  more  exten- 
sive cases  of  this  kind.  The  removal  of  certain  deep-seated  angiomas 
may  be  difficult  or  impossible  because  of  their  connection  with  impor- 
tant bloodvessels  of  the  neck.  Preliminary  clamping  of  the  large 
vessel  trunks,  as  suggested  by  Crile  might  make  it  possible  to  remove 
certain  of  these  tumors.  The  method  suggested  by  Wyeth  of  injectmg 
boiling  hot  water  is  applicable  to  a  good  many  cases,  and  other  ^Titers 
have  suggested  the  injection  of  carbolic  acid  or  iodin  and  the  use  of 
the  cautery  and  the  electric  needle  in  the  more  extensive  cases.  Excis- 


718 


SURGERY  OF   THE  NECK 


ion  of  superficial  neuromas  is  not  usually  attended  with  any  particular 
difficulty  or  danger.  In  the  more  extensive  fibroma  moUuscum  it  ma>- 
be  necessary  to  do  extensive  skin  grafting.  Rem()\'al  of  the  deeply 
seated  neuromas  may  be  attended  by  considerable  difficulty  or  danger. 
If  they  are  attached  to  the  pneumogastric  nerve,  resection  of  the  nerve 
may  be  necessary.  This  results  in  difficulty  in  breathing  and  some- 
times in  temporary  arrest  of  the  heart  action.  However,  the  nerve  has 
been  resected  in  a  good  many  cases,  especially  in  excision  of  malignant 
glands  of  the  neck,  and  without  a  very  large  percentage  of  fatalities. 
Traction  on  the  nerve  and  clamping  it  are  especially  to  be  avoided 
during  the  operation  as  it  may  cause  sudden  respiratory  or  heart 
failure.  Resection  of  the  nerve  gives  rise  to  more  or  less  permanent 
hoarseness  because  of   the  involvement  of   the  recurrent   laryngeal 

branch  and  sometimes  a  good 
deal  of  respiratory  difficulty 
which  usually  clears  up  in  time. 
Malignant  Tumors  of  the 
Neck. — Carcinoma. — The  malig- 
nant tumors  of  the  neck  include 
primary  carcinoma,  metastatic 
carcinoma,  sarcoma,  and,  for 
convenience  in  discussion,  Hodg- 
kin's  disease,  although  there  is 
doubt  whether  it  really  belongs 
in  this  group.  Primary  carci- 
noma of  the  neck  probably 
arises  from  remnants  of  the 
branchial  clefts,  or  in  other  cases 
takes  its  origin  in  old  scars  or  ul- 
cers of  the  skin.  Primary  carci- 
noma is  not  common,  but  second- 
ary involvement  of  the  glands  of 
the  neck  from  carcinoma  in  other 
neighboring  parts  of  the  body  is 
of  frequent  occurrence.  There  is 
little  difficulty  in  the  diagnosis  of  carcinoma  or  epithelioma  arising  in 
scars  or  old  ulcers  of  the  neck.  Malignancy  may  also  develop  in  old  seba- 
ceous cysts  of  the  neck.  The  carcinomas  supposed  to  take  their  origin  in 
the  branchial  cleft  remnants  are  less  common.  A  diagnosis  could  prob- 
ably not  be  made  with  any  degree  of  certainty  as  to  primary  carcinoma 
of  the  neck.  The  consistency,  irregular,  nodular  feel,  involvement  of 
neighboring  organs,  rapid  growth  and  cachexia  would  be  very  sug- 
gestive. The  diagnosis  of  primary  carcinoma  from  metastatic  carci- 
noma would  depend  on  the  discovery  of  some  primary  source  of  disease 
about  the  face,  lip,  tongue,  floor  of  the  mouth,  tonsils,  the  esophagus, 
trachea,  nose,  etc.  Among  the  non-carcinomatous  tumors  there  would 
have  to  be  differentiated  actinomycosis,  or  tuberculosis  of  the  glands  of 
the  neck,  or  one  of  the  forms  of  lymphosarcoma.     A  discussion  of  the 


Fig.  500. — Malignant  lymphoma  of  the  neck. 
Late  stage,     (de  Quervain.) 


TUMORS  OF  THE  NECK  719 

differential  diagnosis  from  tuberculous  involvement  of  the  glands  of  the 
neck  is  given  in  detail  in  that  section;  the  diagnosis  from  actinomycosis 
under  the  discussion  of  that  subject.  Lymphosarcoma  would  be  dis- 
tinguished by  the  softer  consistency,  less  nodular  feel  and  less  tendency 
to  involve  the  skin  and  superficial  structures.  A  positive  diagnosis  is 
sometimes  impossible  even  when  tissues  are  examined  microscopically; 
however,  if  the  microscopic  and  gross  appearance  are  taken  with  the 
clinical  history,  diagnosis  is  usually  sufficiently  clear. 

Sarcoma. — ^A  number  of  names  have  been  given  to  tumors  of  this  class 
occurring  in  the  neck.  Clinically  the  lymphatic  glands  are  almost 
invariably  involved,  the  involvement  being  either  multiple  or  affecting 
only  a  single  gland  or  group  of  glands.  When  confined  to  a  single 
gland  or  group  of  glands  it  is  sometimes  spoken  of  as  lymphosarcoma. 
Formerly  the  Hodgkin's  cases  were  classed  among  the  sarcomas, 
although  because  of  doubt  as  to  cause  there  has  been  a  good  deal  of 
difference  of  opinion.  Recent  studies  seem  to  indicate  that  these 
cases  belong  among  the  infections  of  the  glands  of  the  neck.  Clin- 
ically there  is  decided  difference  between  the  single  and  multiple 
lymphosarcoma  of  the  neck.  The  single  lymphosarcoma  grows 
rapidly  and  soon  breaks  through  the  capsule,  involving  surrounding 
organs  and  becoming  adherent  to  adjacent  structures,  eventually 
breaking  through  the  skin  to  form  large  ulcerated  surfaces  with  the 
outgrowth  of  granulations.  Hodgkin's  disease  or  malignant  lymphoma, 
on  the  other  hand,  is  at  first  rather  slow  in  its  development.  The  growth 
is  well  encapsulated ;  it  does  not  involve  surrounding  organs ;  and  does 
not  infiltrate  the  skin  or  break  through  to  become  ulcerated  even  in 
the  advanced  stages.  -The  growth  in  both  cases  is  at  first  freely  mov- 
able. The  single  lymphosarcoma  grows  more  rapidly  and  the  tumor  is 
at  first  rounded  but  later  becomes  quite  nodular  and  adherent  to  the 
surrounding  muscles  and  tissues.  Microscopically  there  is  a  type  of 
sarcoma  which  takes  its  origin  from  the  connective  tissue  of  the  glands 
and  has  the  character  of  the  simple  spindle  cell  or  alveolar  sarcoma. 
Clinically -the  course  of  these  growths  is  identical  and  a  clinical  dis- 
tinction is  impossible.  Even  a  histological  differential  diagnosis  is 
often  very  difficult,  for  large  cells  frequently  appear  in  these  growths, 
which  strikingly  resemble  spindle  cells. 

Hodgkin's  Disease,  multiple  lymphosarcoma  or  malignant  lymphoma 
is  characterized  by  a  progressive  hyperplasia  of  the  lymphatic  glands. 
It  is  to  be  distinguished  clinically  from  tuberculosis  of  the  glands  of  the 
neck,  or  carcinomatous  involvement  of  the  glands  of  the  neck,  as  well 
as  from  single  lymphosarcoma  by  the  fact  that  the  growth  is  strictly 
limited  within  the  capsule  even  when  extensive  involvement  has  taken 
place.  There  is  never  any  softening,  caseation  or  necrotic  breaking 
down  of  the  gland  substance  as  is  so  common  in  tuberculosis  of  the 
glands  of  the  neck  and  as  may  occur  with  carcinomatous  involvement. 
The  disease  usually  appears  in  adolescence  or  early  adult  life,  although 
it  frequently  affects  children  and  people  of  more  advanced  age.  It 
begins  as  a  glandular  swelling  on  one  side  of  the  neck  without  any  other 


720  SURGERY  OF  THE  NECK 

symptoms  whatever.  This  swelHng  is  slowly  progressive  and  in  the 
course  of  months  it  forms  a  somewhat  nodular  tumor  which  occupies 
the  entire  side  of  the  neck  from  the  jaw  to  the  clavicle.  In  most  cases 
there  are  no  general  symptoms  at  this  time,  but  there  is  usually  a 
rapid  increase  in  growth  with  involvement  of  the  glands  of  the  opposite 
side  of  the  neck,  the  axilla,  the  inguinal  region,  and  in  many  cases  the 
mediastinal  glands.  As  distant  groups  of  glands  become  involved 
general  symptoms  develop;  the  patient  loses  appetite  and  strength  and 
becomes  rapidly  anemic;  and  in  case  of  mediastinal  involvement  there 
is  apt  to  be  a  good  deal  of  difficulty  in  breathing,  or  in  certain  cases 
persistent  cough.  In  some  instances  death  results  from  pressure  of 
the  growth  upon  the  trachea  before  general  symptoms  have  developed 
or  before  general  involvement  has  occurred.  The  diagnosis  in  the 
advanced  cases  is  very  easy  because  of  the  characteristic  symptoms,  but 
in  the  early  stages  of  the  disease  it  is  absolutely  impossible.  The 
absence  of  any  focal  infection  of  the  tonsils,  mouth  or  skin  would  usually 
rule  out  simple  glandular  hyperplasia.  The  normal  blood  picture 
differentiates  it  from  the  glandular  involvement  occurring  with  leu- 
kemia. In  doubtful  cases  excision  of  a  gland  for  microscopic  examina- 
tion should  be  undertaken.  Possibly  the  injection  of  material  into  a 
guinea-pig,  the  use  of  the  tuberculin  test,  and  the  Wassermann  reaction 
might  be  indicated.  While  there  is  nothing  characteristic  in  the  blood 
picture,  the  increase  in  eosinophiles  may  be  of  diagnostic  significance. 
In  the  past  blood  cultures  and  examination  of  tissues  removed  have 
failed  to  show  any  microorganism  which  could  be  looked  upon  as 
the  probable  cause  of  the  disease  or  as  of  any  diagnostic  value,  but 
studies  by  Bunting  and  Yates^  have  shown  a  diphtheroid,  non-acid-fast, 
Gram-staining  bacillus  in  cultures  from  a  number  of  cases;  inoculation 
tests  w4th  monkeys  later  gave  characteristic  glandular  changes.  This 
organism  is  probably  identical  with  that  described  by  Fraenkel  and 
Much  in  1910  and  Billings  and  Rosenow^  have  confirmed  previous 
observations.  Rosenow  has  isolated  this  organism  from  an  abscess 
at  the  root  of  a  tooth  and  from  the  tonsil.  In  the  advanced  stage  of  the 
disease  there  is  sometimes  fever,  and  the  Staphylococcus  aureus  has 
been  sometimes  found  in  the  blood,  but  this  probably  should  be  looked 
upon  as  a  terminal  infection  and  not  as  of  any  particular  significance  in 
relation  to  the  disease. 

Tumors  of  Carotid  Gland. — ^Tumors  of  carotid  gland  are  of  relatively 
infrequent  occurrence,  although  since  attention  has  been  called  to  these 
tumors  in  several  valuable  articles  in  recent  years,  the  number  reported 
has  rather  rapidly  increased.  Keen's  article  was  the  first  in  recent 
times  and  Randolph  Winslow  reported  72  cases  up  to  September,  1916. 
A  later  paper  by  Lund  places  the  total  at  about  100,  although  he  does 
not  give  references  for  additional  cases  following  Winslow's  publica- 
tion. The  carotid  body  is  located  at,  or  just  posterior,  to  the  bifurca- 
tion of  the  common  carotid  artery.     It  is  most  fully  developed  in  fetal 

1  Arch.  Int.  Med.,  August,  1913. 

'  Jour.  Am.  Med.  Assn.,  December  13,  1913. 


TUMORS  OF  THE  NECK  721 

life,  gradually  disappearing  later.  Some  believe  it  belongs  to  the  s\Tnpa- 
thetic  nervous  system  and  to  the  chromatin  group;  others  consider  it  a 
vascular  organ  or  suggest  analogy  to  the  adrenals  and  is  not  a  gland 
in  the  usual  sense  of  the  term,  although  sometimes  spoken  of  as  the 
carotid  gland.  If  it  persists  in  later  life  malignancy  is  apt  to  develop. 
^Microscopically  these  growths  are  usually  classed  as  endothelioma,  or 
perithelioma.  It  is  generally  mildly  malignant  early  in  its  develop- 
ment but  later  tends  to  become  carcinomatous. 

The  first  s\Tnptom  noticed  is  usually  a  small  oval  enlargement  in  the 
superior  carotid  triangle,  which  is  frequently  mistaken  for  an  enlarged 
lymphatic  gland.  Subjective  symptoms  are  usually  absent  although 
there  is  occasionally  radiating  pain  or  a  sense  of  discomfort.  In  most 
cases  increase  in  size  is  slow  although  occasionally  rapid  from  the  start. 
When  brought  to  the  attention  of  the  surgeon  the  growth  generally 
has  a  history  of  several  years'  gradual  enlargement.  In  adult  patients 
it  is  smooth,  rounded,  firm  and  elastic,  fairly  freely  movable  lateral!}^ 
but  not  vertically.  There  is  no  expansile  pulsation  although  this  has 
been  reported  by  some  observers.  Involvement  of  the  cranial  and 
s^'mpathetic  nerves  is  frequent  in  the  later  history  of  these  growths, 
manifested  by  hoarseness,  difficulty  in  speaking,  from  paralysis  of  the 
recurrent  lar\Tigeal  nerve,  or  in  swallowing  if  the  glossopharyngeal 
nerve  is  im'olved,  or  by  irregularity  of  the  pulse  in  case  the  s^Tupathetic 
is  affected.  Deafness  and  conjunctivitis  have  also  been  mentioned. 
Cachexia  and  anemia  are  present  only  in  the  terminal  stages. 

Diagnosis. — A  diagnosis  was  seldom  made  in  the  earlier  cases  reported, 
but  as  the  clinical  features  of  this  condition  are  better  known  it  is 
being  recognized  with  increasing  frequency.  The  slow,  steady  growth 
differentiates  it  from  tuberculosis  of  the  lymphatic  glands;  lack  of 
true  expansile  pulsation  and  bruit  from  aneurysm ;  its  location  and  lack 
of  characteristic  s\Tnptoms  from  thyroid  enlargement  although  aber- 
rant thyroid  and  carcinoma  or  sarcoma  of  the  glands  of  the  neck  are 
difficult  of  difterentiation. 

Treatment. — ^Recent  WTiters  practically  all  agree  that  early  operation 
is  advisable.  In  certain  instances,  if  taken  early,  it  is  possible  to 
dissect  the  tumor  from  the  vessels  without  serious  injury  and  with  a 
reasonable  prospect  of  freedom  from  recurrence.  In  cases  of  long 
standing  there  is  usually  such  extensive  involvement  of  important 
structures  that  closure  of  all  three  carotid  vessels  is  essential  for  com- 
plete excision  of  the  growth.  All  writers  speak  of  the  great  vascularity 
of  these  growths  and  the  tendency  to  serious  hemorrhage.  In  the 
advanced  cases  there  is  serious  nerve  involvement  in  almost  all.  Keen 
found  only  7  out  of  26  cases  free  from  nerve  SATuptoms.  If  operated 
upon  early  it  is  usually  encapsulated  but  later  the  extensive  involve- 
ment of  surrounding  tissues  makes  necessary  the  sacrifice  of  scA'eral 
important  nerves  in  many  cases.  In  an  ad^^anced  case  operated  upon 
by  the  writer,  the  hypoglossal,  glossopharjTigeal  and  lower  division 
of  the  facial  were  aU  sacrificed  but  this  patient  remains  free  from 
recurrence  over  three  years  from  the  date  of  the  operation.     Closure 

VOL.  I — 46 


722  SURGERY  OF  THE  NECK 

of  the  common  carotid  artery  alone,  of  course,  involves  serious  risks, 
because  of  interference  with  the  cerebral  circulation.  Up  to  the  time 
of  this  writing,  however,  most  of  the  cases  reported  have  been  so  far 
advanced  as  to  make  the  more  conservative  dissection  from  the  vessels 
impractical  so  far  as  permanent  cure  is  concerned.  The  choice  lies 
between  a  high  immediate  mortality  with  good  prospect  of  permanent 
cure  or  a  much  lower  immediate  mortality  with  a  ^'ery  high  percentage 
of  deaths  from  recurrence.  \Yinslow  reports  11  deaths  in  34  cases, 
in  which  all  three  carotids  were  ligated  and  the  growth  excised,  or 
nearly  33  per  cent,  immediate  mortality.  On  the  other  hand  24  out 
of  25  recovered  when  the  growth  was  dissected  from  the  vessels  but 
speedy  recurrence  followed  in  8  cases.  The  temporary  closure  of  the 
common  carotid  by  Matas'  aluminum  bands  might  be  tried  as  the  band 
can  be  very  readily  removed  in  case  serious  cerebral  s^Tnptoms  arise. 
The  closure  of  the  vessels  by  suture  instead  of  by  ligature,  will  save  at 
least  one-half  inch  of  the  carotid  artery,  with  correspondingly  better 
prospect  of  good  collateral  circulation.  Suture  is  also  a  safer  method, 
especially  with  somewhat  thickened  and  sclerotic  vessels.  This 
method  was  used  in  2  cases  operated  upon  by  the  writer,  with  an 
excellent  permanent  result  in  each.  In  a  third  case  the  growth  was 
dissected  from  the  vessels  and  radium  treatment  was  used  after  heal- 
ing but  the  growth  promptly  recurred  in  spite  of  this  and  the  patient 
died.  All  writers  report  a  high  mortality.  Up  to  the  date  of  Lund's 
paper  the  operative  mortality  was  estimated  at  25  per  cent,  but  with 
earlier  diagnosis  and  improved  methods  it  should  be  very  much  lower. 

Treatment  of  Malignant  Growths  of  the  Neck.^ — Because  of  the 
advanced  stage  of  the  disease  in  which  most  of  the  malignant  growths 
come  to  the  surgeon  the  outlook  for  surgical  treatment  of  any  sort  is 
most  unsatisfactory.  The  attempt  at  radical  removal  of  extensive 
malignant  growths  of  the  neck  is  followed  by  such  \'ery  discouraging 
results  that  it  would  seem  in  the  interest  of  surgery  to  refuse  radical 
operation  in  the  majority  of  cases. 

Palliative  Operations. — The  curettement  of  the  extensive  sarcomatous 
or  carcinomatous  growths  and  the  application  of  zinc  chloride  or  other 
caustics  frequently  offers  some  relief  from  pain,  bleeding  and  foul  dis- 
charge. These  measures  have  no  permanent  curative  value  of  course. 
The  branchiogenetic  carcinomata  of  the  neck  have  not  as  great  ten- 
dency to  recurrence  locally,  or  to  metastasis,  as  many  forms  of  malig- 
nant growth,  and,  if  taken  early  and  removed  thoroughly  according  to 
the  general  principles  of  operation  upon  the  neck  which  have  been  laid 
down,  fairly  satisfactory  results  might  be  expected.  In  case  the  glands 
of  the  neck  are  involved  secondarily,  the  early  removal  of  the  primary 
growth  followed  by  a  thorough  block  dissection  of  the  neck  followed  by 
intensive  .r-ray  or  radium  treatment  has  given  a  reasonable  percentage 
of  cures  and  is  very  well  justified.  In  Hodgkin's  disease  as  the  growth 
usually  begins  entirely  locally  without  any  apparent  involvement  of 
surrounding  organs,  radical  excision  early  would  seem  to  be  indicated. 
Excision  later  in  the  disease  when  extensive  involvement  has  occurred 


TUMORS  OF  THE  NECK 


723 


is  absolutely  useless,  so  far  as  any  hope  of  a  permanent  cure  is  con- 
cerned. The  use  of  arsenic  in  both  carcinoma  and  the  various  forms  of 
sarcoma  of  the  neck  has  long  had  many  advocates.  It  may  be  given 
by  the  mouth  in  the  form  of  Fowler's  solution  in  doses  of  5  minims, 
three  times  a  day,  increasing  1  minim  a  day  until  30  or  40  minims  are 
given  three  times  a  day,  then  dropping  back  to  the  smaller  dose  and 
beginning  over  again;  or  the  arsenate  of  soda  granules  have  sometimes 
been  used  in  somewhat  similar  manner.  For  many  years  the  injection 
of  arsenic  directly  into  the  growth  has  also  been  practised  with  a  few 


Fig.  501. — Showing  result  three  years 
after  excision  of  carotid  gland  tumor  with 
extensive  involvement  of  important  struc- 
tures of  the  neck.  Paralysis  of  the  de- 
pressor labii  inferioris  from  section  of  lower 
filament  of  the  facial  nerve  shows  fairly  well. 
See  Fig.  503  (Dowd,  Annals  of  Surgery). 
The  carotid  arteries  were  closed  by  suture 
instead  of  ligature. 


Fig.  502. — Result  eight  years  after 
excision  of  extensive  carcinoma  arising 
in  brachial  cleft  cyst  and  infiltrating 
great  vessel  sheaths,  trachea  and 
larynx.  The  thyroid  gland  was  re- 
moved with  the  growth.  The  patient 
has  received  treatment  with  radium 
at  intervals  since  the  operation.  The 
slight  scar  left  bj^  incision  along  the 
natural  folds  of  the  neck  is  also  shown. 


favorable  results  reported.  Recently  intravenous  or  subcutaneous 
use  of  salvarsan  has  been  advocated  and  a  number  of  favorable  results 
have  been  reported  in  Hodgkin's  disease.  In  other  cases  failures  are 
reported.  Very  enthusiastic  reports  have  come  recently  regarding  the 
use  of  the  .r-ray  in  the  treatment  of  Hodgkin's  disease,  but  sufficient 
time  has  not  yet  elapsed  to  determine  whether  these  results  will  be 
permanent  or  not.  There  would  seem  to  be  no  objection  to  the  use  of 
radium  or  the  .r-ray  as  an  after-treatment  in  case  radical  excision  had 
been  performed.  Some  of  the  results  of  the  use  of  radium  after  radical 
operation  have  seemed  to  be  encouraging  and  to  warrant  a  further  trial 


724  SURGERY  OF  THE  NECK 

of  this  means  of  treatment.  The  use  of  the  Coohdge  tube  with  more 
accurate  methods  of  .r-ray  dosage  may  give  more  favorable  results  in 
some  of  these  cases.  The  vaccine  of  Bunting  and  Yates  has  not  yet 
been  given  a  sufficient  trial  to  determine  its  value,  but  the  results 
thus  far  have  been  favorable  enough  to  warrant  further  use  of  this 
method.  Billings  and  Rosenow  report  1  apparent  cure  from  vac- 
cines and  .r-ray  with  improvement  in  6  others.  The  pitiable  state 
of  many  of  these  patients  with  malignant  disease  of  the  neck  has  led 
many  surgeons  to  undertake  operations  in  which  there  is  little  hope 
of  permanent  relief.  Probably  in  no  class  of  cases  have  more  extensive 
and  mutilating  radical  operations  been  performed  and  with  more  dis- 
couraging results.  Such  extensive  operations  which  do  not  give 
permanent  cures  are  apt  to  bring  reproach  upon  surgery  and  should 
generally  be  discouraged. 

Very  encouraging  reports  have  come  from  Kelly  and  others  who  have 
used  radium  in  many  cases,  especially  of  sarcoma  of  the  neck.  If  this 
form  of  treatment  is  used  it  seems  especially  important  to  repeat  the 
treatment  at  intervals,  and  to  keep  these  patients  under  observation 
for  a  long  period  of  time  after  they  ha\e  been  apparently  cured  and 
to  remove  any  renniant  of  the  growth  which  may  remain  after  the 
principal  portion  has  been  removed  by  the  use  of  radium. 

OPERATIONS  OF  THE  NECK. 

In  the  antiseptic  preparation  of  the  field  of  operation  the  sensitiveness 
of  the  skin  of  this  region  should  be  kept  in  mind,  particularly  in  chil- 
dren who  are  so  frequently  subjects  for  neck  operations.  Too  diligent 
scrubbing  by  conscientious  nurses  and  assistants  occasionally  gives 
abrasion  of  the  skin  which  amounts  to  -a  brush  burn  and  the  use  of 
strong  antiseptics  not  infrequently  causes  blistering.  It  is  desirable 
in  the  preparation  of  the  skin  of  any  part  of  the  body  that  the  time  be 
carefully  watched  in  order  to  obtain  certain  results,  with  the  fact  in 
mind  that  a  prolonged  gentle  scrub  is  more  effectual  than  too  vigorous 
shorter  preparation. 

The  position  of  the  patient  on  the  table  deserves  consideration 
because  it  decidedly  influences  venous  oozing.  In  order  to  get  room  for 
satisfactory  work,  the  chin  must  be  thrown  back  and  if  the  patient  is 
in  a  horizontal  position  this  greatly  aggravates  venous  hemorrhage. 
If  local  anesthesia  or  gas-and-oxygen  anesthesia  are  used  it  has  proved 
entirely  safe  to  put  the  patient  in  a  partly  sitting  position  with  the 
head  thrown  far  back.  If  this  is  considered  unsafe  the  entire  table  may 
be  tilted  at  an  angle  of  20  to  30  degrees.  It  is  surprising  how  much 
position  influences  the  activity  of  venous  ooze  which  so  greatly  inter- 
feres with  the  careful  dissection.  In  operating  in  the  lower  triangle 
of  the  neck  a  small  sand-bag  or  hard  pillow  between  the  shoulders 
allows  the  shoulder  to  fall  back  and  in  some  cases  further  room  can  be 
obtained  by  an  assistant  making  gentle  traction  downward  on  the 
arm.    Throwing  the  head  far  backward  not  only  gives  a  great  deal 


OPERATIONS  OF  THE  NECK 


725 


more  room  between  the  chin  and  the  sternum  and  clavicle,  but  it 
carries  the  muscles  and  great  vessels  of  the  neck  backward  making  the 
dissection  of  the  upper  triangle  very  much  easier.  Of  course  the  head 
has  to  be  turned  away  from  the  affected  side  m  operating  upon  the 
side  of  the  neck. 

Protection  of  the  Field  of  Operation. — The  operative  wound  is  fre- 
quently located  so  near  to  the  mouth  that  unless  special  measures 
are  taken  there  is  risk  of  wound  contamination  from  coughing,  vomiting 
or  manipulations  of  the  anesthetist.    In  protecting  the  field  we  have 


Fig.  503, 


-Two  incisions  which  give  access  to  a  large  part  of  the  neck  and  leave  little 
scar  above  the  coUar-line.     (Dowd,  Annals  of  Surgerj-.) 


found  the  Kocher  screen  most  satisfactory.  ^Yhen  applied  closely 
just  under  the  chin  it  gives  ample  room  for  the  operator  and  assistants 
and  perfectly  protects  the  field  whatever  the  anesthetist  may  be 
called  upon  to  do.  A  cap  to  hold  the  patient's  hair  in  place  and  wet 
towels  bornid  around  the  head  help  to  protect  the  field  of  operation. 
Protective  dressings  may  also  be  secured  to  the  edges  of  the  wound  by 
towel  clamps. 

A  number  of  plans  have  been  suggested  regarding  the  adminis- 
tration of  the  anesthetic  so  as  to  prevent  wound  contamination.  With 
this  in  view  some  surgeons  prefer  the  use  of  rectal  anesthesia:  others 


726  SURGERY  OF  THE  NECK 

use  intratracheal  tubes  or  pharyngeal  tubes  inserted  either  through 
the  nose  or  at  the  angle  of  the  mouth.  If  the  operative  field  is  not 
too  extensive  and  deeper  structures  are  not  extensively  involved,  local 
anesthesia  is  perfectly  satisfactory  in  the  great  majority  of  cases,  and 
avoids  certain  risks  connected  with  any  form  of  general  anesthesia. 
With  rectal  anesthesia  we  have  no  control  over  the  dose  after  the  anes- 
thetic is  once  administered  and  there  is  also  considerable  risk  of  bowel 
inflammation  which  would  seem  to  contra-indicate  this  method  in  the 
majority  of  cases.  There  have  been  too  many  postoperative  respira- 
tory complications  following  the  use  of  intratracheal  anesthesia  to 
make  it  seem  desirable  in  most  cases.  It  would  seem  to  be  definitely 
indicated  in  those  rather  rare  cases  in  which  there  is  erosion  of 
the  tracheal  rings  or  dangerous  pressure  upon  the  air  passages.  Even 
in  these  cases  local  anesthesia  is  frequently  perfectly  satisfactory. 
There  would  seem  to  be  no  serious  objection  to  the  use  of  pharyngeal 
tubes  either  through  the  nose  or  introduced  to  the  pharynx  through  the 
mouth,  but  if  the  Kocher  screen  is  used  to  protect  the  field  of  operation 
from  the  anesthetist's  field,  there  would  be  little  use  for  any  of  these 
methods.  ^Yith  the  use  of  the  Kocher  screen  gas  and  oxygen  can  be 
used  through  a  small  mask  or  ether  may  be  given  by  the  drop  method 
without  any  difficulty.  In  case  of  coughing,  vomiting  or  difficulty  in 
respiration  the  anesthetist  can  make  all  necessary  manipulations  w^ith- 
out  serious  risk  of  contaminating  the  operati\e  field.  The  method  of 
administering  ether  described  in  the  section  on  Surgery  of  the  Thyroid 
Gland,  can  be  used  advantageously  in  almost  all  other  operations  of 
the  neck. 

The  skin  incisions  in  the  line  of  the  natural  folds  of  the  neck  give 
ample  room  for  operation  in  the  majority  of  these  cases.  If  necessary 
they  may  be  combined  with  an  incision  along  the  posterior  part  of  the 
neck  within  the  hair-line.  In  case  it  is  necessary  to  divide  muscles  in 
order  to  get  satisfactory  exposure  of  deeper  structures  it  is  desirable 
to  place  the  skin  and  muscle  incision  at  a  dift'erent  level  so  that  there 
may  not  be  a  scar  extending  directly  from  the  skin  into  the  underlying 
muscles  which  draws  every  time  the  muscle  contracts.  This  is  par- 
ticularly true  of  operations  in  the  neighborhood  of  the  larynx  and 
trachea.  It  is  also  important  when  muscles  are  divided  that  the  nerve 
supply  should  be  kept  in  mind  and  it  is  usually  possible  to  place  the  cut 
in  such  a  position  that  the  muscle  is  not  parah'zed.  Possibly  the  two 
most  important  applications  of  this  principle  are  found  w4th  the  sterno- 
mastoid  which  when  di^'ided  a  short  distance  above  the  sternum  and 
clavicle,  retains  uninjured  its  nerve  supply  from  the  spinal  accessory 
and  spinal  nerves  and  the  sternohyoid  and  sternothyroid  muscles 
which  if  divided  near  the  hyoid  bone  leave  uninjured  the  nerve  supply 
from  the  descending  loop  of  the  hypoglossal  nerve.  Occasionally  two 
skin  incisions  at  different  levels  give  more  satisfactory  exposure  with 
less  disfiguring  scar  than  a  single  extensive  incision.  Extensive  dis- 
sections along  the  bloodvessels  are  accompanied  with  considerable 
risk  of  bleeding  which  can  be  usually  avoiderl  if  the  vessels  are  thor- 


OPERATIONS  ON  THE  LARYNX  AND  TRACHEA  727 

oughly  exposed  and  care  is  taken  to  secure  all  branches  carefully  and 
avoid  undue  force  and  the  tearing  of  vessel  walls.  To  prevent  danger- 
ous hemorrhage  in  extensive  block  dissections  of  the  neck  the  use  of 
temporary  vessel  clamps  has  been  suggested.  The  experience  of  Crile 
and  others  has  shown  that  such  temporary  compression  is  not  harmful 
and  that  it  is  an  efficient  means  of  preventing  serious  hemorrhage  in 
extensive  neck  dissections.  Unfortunately  in  the  case  of  many  exten- 
sive growths  of  the  neck  the  vessels  which  we  would  desire  to  secure  are 
covered  by  the  growth  so  that  it  is  not  possible  to  secure  them  before 
beginning  the  dissection.  As  a  rule  the  chief  essentials  for  successful 
neck  surgery  are  time,  patience  and  care;  securing  each  bloodvessel 
between  clamps  before  it  is  divided  and  in  the  case  of  the  larger  vessels 
immediate  ligation,  using  two  ligatures  on  the  more  important  trunks. 
No  operations  in  the  body  require  a  more  thorough  knowledge  of 
anatomy  or  more  painstaking  care.  The  special  risks  involved  in  the 
operation  for  tuberculous  glands  of  the  neck  will  be  mentioned  under 
that  heading.  Securing  the  platysma  and  superficial  fascia  is  an  aid  to 
a  better  result  as  regards  the  after- scar.  As  numerous  small  vessel 
trunks  and  lymphatic  spaces  are  involved  in  all  the  extensive  neck 
operations,  drainage  is  usually  desirable  for  the  best  results.  Sometimes 
several  twisted  strands  of  silkworm  gut  inserted  into  one  angle  of  wound 
is  all  that  is  needed.  In  other  cases  more  extensive  drainage  with  the 
use  of  tube  or  cigarette  drains  would  be  desirable.  As  a  rule  the  drain- 
age can  be  removed  within  tji'e  first  twenty-four  or  forty-eight  hours 
unless  infection  is  present.  Extensive  loss  of  blood  should  be  met  by 
the  use  of  transfusion  or  free  use  of  fluid  by  rectum  if  it  occurs.  Patients 
are  usually  more  comfortable  with  the  head  slightly  raised  and  we  fre- 
quently place  them  in  a  partial  sitting  position  on  a  Gatch  bed.  Early 
removal  of  stitches  as  well  as  of  drainage  is  an  aid  in  securing  better 
cosmetic  results.  The  stitches  may  be  removed  as  early  as  the  first  or 
second  day  following  operation  and  the  wound  edges  secured  by  the 
use  of  a  collodion  dressing.  Usually  there  is  considerable  difficulty  in 
swallowing  following  extensive  dissections  for  two  or  three  days,  mak- 
ing it  advisable  to  use  a  liquid  diet.  Dissections  of  the  upper  part  of 
the  neck  frequently  involve  some  bruising  of  the  parotid  and  the 
patients  should  be  cautioned  that  he  is  likely  to  have  what  looks  like 
mumps  after  the  operation  but  that  it  will  soon  disappear. 

OPERATIONS  ON  THE  LARYNX  AND  TRACHEA. 

Five  methods  of  attack  have  been  used  in  operating  for  growths  or 
diseased  conditions  of  the  larynx:  (1)  The  endolaryngeal  route  with 
reflected  light  through  the  mouth.  (2)  Thyreotomy:  splitting  the 
cartilages  of  the  larynx  to  get  access  to  diseased  conditions  within. 
(3)  Pharyngotomy :  opening  the  pharynx  either  above  or  below  the 
hyoid  bone  to  get  access  to  growths  within  the  larynx.  (4)  Partial 
laryngectomy:  for  removal  of  growths  involving  a  portion  of  the 
larynx  itself.  (5)  Total  laryngectomy;  used  in  the  removal  of  disease 
involving  the  entire  larynx  or  nearly  the  entire  larynx. 


728  SURGERY  OF  THE  NECK 

Endolaryngeal  removal  of  many  benign  growths  and  other  diseased 
conditions  has  been  the  preferred  route  by  laryngologists  for  many 
years.  This  method  of  operating  is  available  only  for  those  who  are 
skilled  in  the  use  of  the  laryngoscope,  operating  with  the  inverted 
image.  Certain  laryngologists  also  prefer  to  use  this  route  because  of 
the  lessened  danger  to  life  in  the  removal  of  small  malignant  growths. 
General  surgeons,  including  von  Bruns,  Kocher,  and  a  number  of  others 
of  high  standing,  condemn  this  method  in  the  remo^•al  of  malignant 
growths  as  offering  insufficient  exposure  and  not  removing  the  disease 
thoroughly  enough.  This  standpoint  is  also  shared  by  a  number  of 
lar\iigologists  of  distinction  who  believe  that  the  cures  by  endo- 
laryngeal methods  reported  by  Frankel  are  the  result  of  a  coincidence 
of  fortunate  circumstances  and  that  such  cures  are  the  unusual  excep- 
tion, rather  than  the  rule.  If  the  growth  were  not  thoroughly  removed 
by  the  endolaryngeal  method,  it  would  certainly  increase  the  rapidity 
of  growth  and  cause  delay  until  the  favorable  time  had  passed  for 
radical  operation,  ^yith  these  facts  in  view  it  would  seem  that  opera- 
tion for  malignant  growths  by  the  endolaryngeal  method  should  be 
abandoned. 


Fig.  504. — Carcinoma  of  the  larynx.     (Preysing.) 

Thjrreotomy. — Thyreotomy  is  considered  by  many  the  normal 
method  of  attack  for  small  growths  that  have  not  caused  extensive 
involvement.  Giving  complete  exposure  of  the  inside  of  the  larynx  it 
may  be  compared  to  an  exploratory  laparotomy  and  in  case  the  disease 
is  too  extensive  to  be  removed  by  thjTcotomy  alone,  the  more  radical 
operation  can  be  applied.  As  the  field  of  operation  is  so  superficial  the 
operation  can  be  carried  out  very  satisfactorily  under  local  anesthesia 
in  many  cases.  About  one  hour  before  the  beginning  of  the  operation 
the  patient  is  given  a  preliminary  sedative  hypodermic  and  is  placed 
upon  the  table  in  the  Trendelenburg  position  with  the  head  hanging 
well  over  the  table  in  order  to  prevent  aspiration  of  blood.  It  is  well 
to  spray  the  larynx  thoroughly  with  a  4  per  cent,  solution  of  cocain 
ten  or  fifteen  minutes  before  the  operation  is  begun  in  order  to  prevent 
violent  coughing  when  the  larynx  or  trachea  is  opened.  If  there  is 
severe  hemorrhage  a  preliminary  tracheotomy  and  the  use  of  the  Hahn 
tampon  cannula  can  be  employed.  The  skin  in  the  middle  line  and 
underlying  tissues  are  infiltrated  with  novocain  solution  and  the 
tissues  are  divided  down  to  the  thjToid  and  cricoid  cartilage.  The 
cartilages  are  then  divided,  opening  into  the  larynx  and  retractors 
inserted  giving  complete  exposure  of  the  interior.     The  mucosa  is 


OPERATIONS  ON  THE  LARYNX  AND  TRACHEA  729 

swabbed  with  a  solution  of  local  anesthetic,  either  cocain  or  novocain 
and  adrenalin.  This  not  only  reduces  the  amount  of  hemorrhage,  but 
prevents  reflex  irritation.  The  diseased  tissues  are  removed  down  to 
the  cartilages,  the  cautery  being  employed  in  removal  of  malignant 
disease  if  preferred.  The  thjToid  cartilage  is  stitched  together,  but  the 
lower  part  of  the  wound  in  the  neighborhood  of  the  trachea  is  left  open. 
The  external  wound  is  also  closed  above  and  a  loose  tampon  is  placed 
in  the  lower  part  of  the  incision.  The  breathing  is  usually  free  and  it  is 
unnecessary  to  use  a  tracheotomy  tube  in  most  cases.  The  voice  is 
sometimes  fairly  well  preserved  by  the  formation  of  a  scar  tissue  band 
which  acts  as  an  artificial  cord.  Some  prefer  the  use  of  a  general 
anesthetic  in  the  operation  for  thyreotomy,  but  the  use  of  local  anes- 
thesia considerably  lessens  the  amount  of  bleeding  and  the  distressing 
tendency  to  cough  following  operation.  In  case  it  seems  necessary  to 
use  the  tampon  cannula  because  of  hemorrhage  or  difficulty  in  breath- 
ing, it  is  usually  possible  to  remove  it  at  the  end  of  the  operation  and 
replace  it  with  a  tracheotomy  tube  which  in  turn  can  be  removed  on  the 
first  or  second  day  after  the  operation.  Patients  are  usually  able  to 
swallow  at  the  end  of  the  first  day. 

Subhyoid  Pharyngotomy. — Subhyoid  pharyngotomy  has  been  em- 
ployed in  a  few  cases  for  the  removal  of  growths  in  the  lower  part  of 
the  pharynx  and  upper  part  of  the  larynx.  Because  of  the  insufficient 
exposure  and  the  greater  danger  of  postoperative  pneumonia  and 
infection  it  has  been  abandoned  by  most  operators  at  present,  however. 
As  a  substitute  for  subhyoid  pharyngotomy  von  Hacker  and  Jere- 
mitsch  have  recently  advocated  the  use  of  suprahyoid  pharyngotomy, 
this  being  suggested  by  the  more  kindly  healing  in  cases  of  attempted 
suicide  and  cut  throats  when  the  cut  in  the  neck  was  made  above, 
rather  than  below  the  hyoid  bone.  The  patient  is  usually  placed  in 
the  Trendelenburg  position  with  the  head  hanging  over  the  table  in 
order  that  blood  may  gravitate  upward  and  not  interfere  with  the 
breathing.  Preliminary  tracheotomy  is  recommended  in  the  majority 
of  cases  and  general  anesthesia  would  usually  be  preferred.  The  skin 
incision  is  made  above  the  hyoid  bone  extending  transversely  from  the 
anterior  border  of  the  sternomastoid  muscle  on*  one  side  to  that  of  the 
other  side.  In  the  division  of  the  deeper  muscles  the  geniohyoid,  the 
mylohyoid  and  the  digastric  muscles  are  usually  divided.  The  incision 
avoids  the  superior  laryngeal  nerve  as  a  rule.  Numerous  bleeding 
points  have  to  be  secured  before  the  mucous  membrane  is  opened  into 
the  pharynx.  This  incision  is  said  to  give  very  satisfactory  exposure 
of  this  region,  making  possible  the  ready  removal  of  growths  located 
in  the  upper  part  of  the  larynx  or  the  lower  part  of  the  pharynx.  The 
wound  should  be  closed  carefully  in  layers,  approximating  the  muscles 
as  satisfactorily  as  possible  and  provision  should  be  made  for  drainage. 

Partial  Laryngectomy. — The  operation  may  be  either  typical  uni- 
lateral excision  of  the  larynx  or  an  atypical  excision  depending  upon  the 
location  of  the  growth  which  is  to  be  removed.  In  certain  cases  almost 
the  entire  larynx  is  removed,  the  operation  approaching  in  extent  a 


730 


SURGERY  OF  THE  NECK 


total  laryngectomy.  Partial  laryngectomy  is  to  be  preferred  to  the 
total  laryngectomy,  however,  in  case  it  is  possible  thoroughly  to  remove 
the  disease  in  this  way  because  of  the  much  better  functional  results, 
which  are  often  surprisingly  satisfactory.  The  patients  are  usually 
able  to  breathe  satisfactorily  without  the  use  of  the  tracheotomy  tube, 
they  frequently  speak  in  a  whisper  and  sometimes  they  have  consider- 
able voice  in  case  a  scar  tissue  band  forms  which  acts  as  a  substitute 
for  the  vocal  cord.  Partial  laryngectomy  is  carried  out  in  very  much 
the  same  way  as  thyreotomy.  If  the  operation  is  extensive,  however, 
a  general  anesthetic  is  usually  necessary.  In  some  of  these  cases  Gluck 
recommends  a  laryngoplastic  operation,  using  a  flap  of  skin  partially 
to  close  the  air  passages.  If  a  very  extensive  resection  is  required, 
probably  total  laryngectomy  would  be  preferable,  because  of  the  lessened 
danger  of  aspiration  pneumonia.  In  the  after-care  of  these  patients,  a 
tracheotomy  tube  is  left  in  place  for  the  first  few  days,  the  wound  is 
tamponed  with  iodoform  gauze  and  the  patient  is  fed  through  a  tube 
in  the  esophagus  for  the  first  five  or  six  days. 


Fig.  505. — Laryngectomy.     Total  extirpation  of  the  larynx.     (Gluck.) 

Total  Laryngectomy. — Total  laryngectomy  is  indicated  in  all  cases 
of  malignant  disease  in  which  eradication  is  impossible  by  less  radical 
procedures,  provided  of  course  that  the  location  and  extent  of  the 
disease  still  permits  of  complete  removal,  and  the  general  condition 
and  strength  of  the  patient  warrants  so  extensive  an  operation.  The 
operation  as  at  present  performed  is  the  outgrowth  of  over  twenty 
years'  experience  and  represents,  as  with  most  important  surgical  pro- 
cedures, contributions  of  many  workers.  The  technic  used  by  Gluck, 
of  Berlin,  probably  combines  the  most  important  improvements  in 
modern  methods  and  includes  valuable  personal  contributions.    Gluck 


OPERATIONS  ON  THE  LARYNX  AND  TRACHEA  731 

uses  a  rectangular  flap  to  expose  the  field  of  operation,  the  base  of  the 
rectangle  being  placed  toward  one  side  and  the  upper  limb  just  above 
the  hyoid  bone.  He  does  not  use  preliminary  tracheotomy  and  advises 
general  anesthesia  under  chloroform.  As  with  most  operations  upon 
the  larynx  the  patient  is  placed  in  the  Trendelenburg  position  with 
the  head  hanging  over  the  table.  The  flap  includes  the  skin,  subcuta- 
neous fat  and  platysma  muscles  and  exposes  the  larynx,  upper  part  of 
the  trachea  and  superficial  muscles  of  the  neck.  The  sternohyoid 
and  sternothyroid  muscles  are  divided  and  drawn  to  one  side.  The 
superior  thyroid  arteries  are  ligated  and  the  trachea  and  larynx  are 
freed  from  attachment  of  surrounding  tissues,  special  care  being  taken 
in  the  separation  of  the  larynx  and  trachea  from  the  esophagus  by 
blunt  dissection.  The  thyrohyoid  membrane  is  then  divided  just  below 
and  parallel  to  the  hyoid  bone;  the  interior  of  the  larynx  and  lower 
part  of  the  pharynx  are  inspected  and  cocainized.  A  tracheotomy  tube 
is  then  inserted  in  the  larynx  and  sutured  in  place  and  the  anesthetic 
is  given  through  a  tube  at  some  distance  from  the  operating  table.  As 
much  of  the  pharynx  is  left  as  it  possible  with  complete  removal  of  the 
disease,  in  order  to  permit  of  complete  closure  of  the  pharynx  over  the 
feeding  tube  later.  The  larynx  having  been  separated  from  all  sur- 
rounding attachments  and  connection  with  the  pharynx  divided  above, 
a  longitudinal  median  line  incision  is  made  down  to  the  sternal  notch. 
The  thyroid  gland  is  then  separated  from  the  trachea,  divided  at  the 
isthmus  and  the  stumps  ligated,  making  it  possible  to  deliver  the  larynx 
and  upper  part  of  the  trachea  into  the  wound.  Stitches  having  been 
placed  with  which  to  anchor  the  trachea,  the  larynx  is  divided  from  the 
upper  part  of  the  trachea  and  the  stump  is  sutured  into  the  incision 
just  above  the  sternal  notch.  A  soft  rubber  feeding  tube  is  then 
passed  through  the  nose  and  pharynx  into  the  esophagus  and  the 
pharyngeal  wound  is  closed  with  a  double  row  of  catgut  sutures  over 
which  are  sutured  the  stumps  of  the  sternohyoid  and  sternothyroid 
muscles.  The  rectangular  wound  is  then  sutured  at  the  upper  and 
lower  border  and  gauze  is  packed  into  the  space  from  the  side.  A 
tracheotomy  tube  is  usually  placed  in  the  tracheal  opening  and  the 
entire  neck  is  covered  with  a  heavy  gauze  dressing.  As  soon  as  the 
patient  has  recovered  from  the  anesthetic  he  is  fed  with  liquids  through 
the  tube  and  should  sit  up  as  soon  as  possible,  usually  the  next  day 
after  operation.  Frequently  the  disease  involves  the  glands  of  the  neck, 
the  upper  part  of  the  trachea  or  esophagus  and  sometimes  the  lower  part 
of  the  pharynx  and  base  of  the  tongue.  Von  Bruns  reports  a  patient 
who  remained  well  for  eight  years  following  complete  laryngectomy, 
also  removal  of  five  upper  rings  of  the  trachea,  the  upper  portion  of 
the  esophagus  and  half  of  the  thyroid  gland.  When  the  disease  involves 
the  upper  part  of  the  esophagus,  or  lower  portion  of  the  pharynx  and 
the  base  of  the  tongue,  it  is  sometimes  impossible  to  suture  the  pharynx 
over  the  feeding  tube.  In  such  cases  a  permanent  fistula  remains  and 
Gluck  feeds  the  patient  by  the  use  of  a  soft  rubber  funnel  feeding  tube 
introduced  through  the  mouth  and  past  the  fistula.    With  this  contriv- 


732  SURGERY  OF  THE  NECK 

ance  the  patient  is  able  to  swallow  liquids  and  soft  diet  taken  by  mouth. 
The  chief  cause  of  mortality  after  operations  upon  the  larynx  has  been 
pneumonia.  The  complete  shutting  off  of  the  trachea  from  the  field 
of  operation  by  placing  the  stump  at  the  lower  angle  of  the  wound  has 
considerably  lessened  this  danger  by  preventing  the  aspiration  of 
saliva,  mucus,  wound  secretions  or  food.  Furthermore  the  closure  of 
the  pharynx  has  also  reduced  the  risk  of  wound  infection  and  has  made 
possible  normal  swallowing.  By  cultivating  speech  soon  after  the 
operation  an  audible  and  clear  pharyngeal  voice  is  sometimes  gained. 
If  this  is  impossible  the  apparatus  suggested  by  Gluck  may  be  used. 
This  consists  of  a  cap  which  is  attached  to  the  tracheotomy  tube  and 
which  has  a  valve  permitting  inspiration.  The  valve  closes  during 
expiration,  however,  and  air  is  carried  through  a  small  tube  inserted 
through  the  nose  into  the  pharynx.  A  reed  in  this  tube  makes  it  pos- 
sible for  the  patient  to  speak,  the  muscles  of  the  pharynx  and  the  acces- 
sory sinuses  performing  their  normal  functions.  Most  other  forms  of 
artificial  larynx  have  been  abandoned  and  because  of  the  ability  to 
cultivate  a  fairly  good  pharyngeal  voice  in  many  cases  it  is  unnecessary 
to  use  any  artificial  apparatus.  It  is  stated  that  modern  methods 
double  the  number  of  permanent  cures  which  have  resulted  from 
operation  in  recent  years,  and  that  over  one-third  of  the  patients 
operated  upon  are  free  from  recurrence.  Laryngectomy,  either  partial 
or  total,  is  also  used  in  case  of  destruction  of  the  cartilages  of  the 
larynx  from  inflammatory  conditions  and  for  extensive  tuberculosis 
of  the  larynx  which  is  not  accompanied  with  serious  invoh'enjent  of 
the  lungs.  As  to  the  choice  of  operation  in  case  of  malignancy,  von 
Bruns  states  that  nearly  half  of  the  patients  are  saved  by  thyreotomy 
if  the  operation  is  undertaken  early.  The  immediate  death-rate  from 
total  and  partial  laryngectomy  is  about  equal,  but  the  functional 
results  of  partial  laryngectomy  are  of  course  superior  to  those  of  total 
laryngectomy.  As  with  carcinoma  of  most  other  parts  of  the  body  the 
question  of  early  diagnosis  is  the  important  one.  With  an  early 
diagnosis  and  suitable  radical  operation  the  results  are  encouraging. 

Tracheotomy.^ — x\mong  all  the  operations  on  the  air  passages, 
tracheotomy  is  the  most  important  both  because  of  its  value  in  saving 
life  in  emergency  and  as  a  preliminary  to  many  of  the  other  operations. 
Whenever  the  air  passages  are  obstructed,  from  whatever  cause, 
tracheotomy  is  indicated;  whether  from  the  presence  of  foreign 
bodies  in  the  air  passages;  inflammatory  processes,  either  acute  or 
chronic,  such  as  diphtheria,  edema  of  the  larynx,  croup  or  tuberculosis. 
Also  from  obstruction  from  new  growths  affecting  the  larynx  or 
trachea;  injury  of  the  larynx  or  trachea;  and  as  a  preliminary  to  other 
operations  on  the  upper  air  passages.  The  trachea  is  opened  in  one 
of  two  locations,  depending  upon  the  conditions  of  the  case.  In  the 
high  tracheotomy,  the  opening  is  usually  made  through  the  ring  of  the 
cricoid  cartilage  and  upper  rings  of  the  trachea,  above  the  isthmus  of  the 
thyroid  gland;  in  low  tracheotomy,  below  the  isthmus  of  the  thyroid. 
High  tracheotomy  is  considered  the  operation  of  choice  when  available, 


OPERATIONS  ON  THE  LARYNX  AND  TRACHEA.  733 

although  some  advise  low  tracheotomy  for  children.  In  many  cases  of 
emergency,  the  patient  is  unconscious  and  no  anesthetic  whatever  is 
necessary.  In  case  of  adults,  local  anesthesia  is  perfectly  satisfactory  in 
the  majority  of  cases.  General  anesthesia  may  be  used  if  preferred.  In 
case  of  emergency,  the  trachea  is  sometimes  opened  with  a  pocket  knife 
and  a  bent  hairpin  or  safety  pin  attached  to  a  string  is  used  as  a 
retractor  to  hold  the  trachea  open.  The  fact  that  the  patients  some- 
times recover  from  such  operations  should  not  lead  us  to  carelessness 
in  the  operation  if  conditions  are  such  that  the  usual  surgical  pre- 
cautions can  be  employed.  The  skin  incision  is  made  in  the  median 
line  and  should  be  reasonably  ample.  The  sternohyoid  and  sterno- 
thyroid muscles  should  be  separated  from  the  larynx,  and  retracted 
toward  either  side.  In  a  high  tracheotomy  the  isthmus  of  the  thyroid 
may  need  retraction  downward  and  in  case  the  isthmus  is  enlarged,  it 
is  sometimes  necessary  to  divide  it.  If  this  is  the  case,  it  is  best  to 
crush  the  gland  with  strong  forceps,  something  like  those  used  by 
Kocher  in  the  goiter  operation  and  ligate  the  stumps  to  avoid  hemor- 
rhage. Sometimes  a  thyroid  lobe  also  obstructs  the  field  of  operation 
and  must  either  be  removed  or  a  low  tracheotomy  substituted.  If 
low  tracheotomy  is  used  the  isthmus  of  the  thyroid  is  retracted  upward 
instead  of  downward  and  special  pains  should  be  taken  to  secure  large 
veins  which  are  sometimes  located  in  this  vicinity.  Unless  the  case 
is  one  of  emergency  the  bleeding  should  be  arrested  before  the  air 
passages  are  opened  in  order  that  the  aspiration  of  blood  may  be 
avoided.  The  trachea  may  be  steadied  by  grasping  the  larynx  between 
the  thumb  and  fingers,  or  better  by  fixing  it  with  a  tenaculum;  or  a 
curved  needle  held  in  a  hemostatic  forceps  may  be  used  in  place  of  a 
tenaculum.  The  wound  in  the  trachea  is  widely  opened  using  a  tracheal 
dilator  if  it  is  available  or  a  blunt-nosed  forceps  may  be  inserted  and  the 
jaws  opened  to  hold  the  incision  apart.  The  opening  in  the  trachea 
should  be  large  enough  to  permit  the  tracheotomy  tube  to  be  inserted 
easily  as,  if  much  pressure  is  used,  there  is  a  tendency  to  pushing  in  of 
the  tracheal  wall  or  the  bending  forward  of  the  posterior  wall  of  the 
trachea  giving  rise  to  formation  of  stenosis  which  it  may  be  a  matter  of 
a  good  deal  of  difficulty  to  overcome.  Obstruction  through  bending 
forward  of  the  trachea  is  also  caused  by  using  too  large  a  tracheotomy 
tube  or  one  with  an  unsuitable  curvature.  To  avoid  this  risk  several 
tubes  of  different  sizes  should  be  available,  suited  to  the  particular  case. 
Sometimes  a  stitch  or  two  is  taken  in  the  skin  incision,  but  it  is  usually 
as  well  to  pack  the  wound  with  gauze  and  to  apply  a  little  moist  gauze 
over  the  opening  of  the  tube.  It  is  desirable  that  air  coming  into  the 
deeper  air  passages  should  be  warm  and  moist.  To  accomplish  this  a 
croup  kettle  is  sometimes  used  and  in  connection  with  this  a  bron- 
chitis tent  is  sometimes  placed  over  the  patient  and  the  steam  from  the 
kettle  carried  under  the  tent  by  means  of  a  tube.  A  packet  of  gauze 
moistened  with  boric  acid  solution  helps  out  somewhat  in  case  it  is 
impossible  to  have  the  patient  inhale  warm  moist  air.  If  the  usual  Luer 
double  tube  is  used  there  is  very  little  difficulty  in  keeping  it  clean  as  a 


734  SURGERY  OF  THE  NECK 

rule.  If  thick  mucus  accumulates  in  the  tube  it  is  sometimes  possible 
to  remove  it  with  a  feather  without  taking  out  the  inner  tube.  Patients 
are  usually  apprehensive  in  regard  to  their  breathing  when  the  tube  is 
at  first  removed  and  sometimes  there  is  more  or  less  coughing,  hoarse- 
ness and  dyspnea,  particularly  at  night,  for  the  first  few  weeks  after  the 
tube  is  removed.  Permanent  disturbance  of  this  sort  is  unusual  and  in 
most  cases  it  disappears  in  a  short  time,  so  soon  as  the  patients  discover 
that  their  real  troubles  are  past.  Permanent  difficulty  in  breathing  is 
sometimes  seen  as  the  result  of  the  accumulation  of  granulation  tissue 
in  the  locality  where  the  tube  was  placed.  Hofmeister  states  that  the 
prognosis  in  these  cases  is  doubtful,  that  death  sometimes  results,  not 
only  in  a  short  time  but  after  several  years  as  the  result  of  persistent 
recurrence  of  granulation.  He  advises  curetting  the  granulations 
away  with  a  small  sharp  curette  and  cauterizing  with  nitrate  of  silver  or 
chloride  of  zinc,  being  careful  to  see  that  none  of  the  caustic  finds  its 
way  to  the  trachea.  Stenosis  of  the  trachea  from  the  bending  forward 
of  the  posterior  tracheal  wall  or  from  the  pushing  inward  of  curve  of 
the  trachea  as  has  already  been  mentioned.  If  the  incision  into  the 
trachea  is  not  made  strictly  in  the  median  line  sometimes  there  is  a 
tendency  toward  infolding  of  the  edges  of  the  tracheal  incision  also 
causing  more  or  less  obstruction.  When  tracheotomy  is  made  in 
preparation  for  some  further  operation  upon  the  upper  air  passages, 
the  entrance  of  blood  is  sometimes  prevented  by  wrapping  a  thin  soft 
sponge  about  the  tracheotomy  tube  as  suggested  by  Hahn.  Others 
have  suggested  attaching  a  bag  of  thin  rubber  which  could  be  blown 
up  by  a  tube  so  as  to  shut  off  the  trachea  and  in  this  way  prevent  the 
access  of  blood  in  the  lower  air  passages.  With  the  patient  in  the 
Trendelenburg  position  and  the  head  hanging  over  the  end  of  the  table 
there  is  much  less  trouble  with  aspiration  of  blood  and  the  necessity 
for  using  the  tampon  cannula  has  almost  disappeared  in  recent  years 
since  local  anesthesia  has  more  generally  been  employed  in  place  of 
general  anesthetic. 


DIEECT  LAEYXGOSCOPY,  BEOXCHOSCOPY 
AND  ESOPHAGOSCOPY. 

By  chevalier  JACKSON,  M.D. 

Direct  laryngoscopy,  bronchoscopy  and  esophagoscopy  are  pro- 
cedures using  electrically  lighted  tubes  for  the  examination  and  treat- 
ment of  the  interior  of  the  larynx,  trachea  and  bronchi  and  the  esopha- 
gus. They  are  performed  with  straight  and  rigid  instruments,  which 
serve  as  tubular  specula  in  drawing  the  obstructing  tissues  out  of  the 
way,  or  by  manipulating  the  tissues  to  be  inspected  into  a  new  position 
in  the  line  of  sight.  Direct  laryngoscopy,  besides  its  use  for  endo- 
laryngeal  examinations  and  operations,  is  a  necessary  preliminary  to  the 
introduction  of  the  bronchoscope.  All  three  procedures  are  used  in  the 
removal  of  foreign  bodies  and  the  diagnosis  and  treatment  of  disease. 
They  are  procedures  free  from  danger  if  skilfully  done;  but  like  all 
purely  manual  procedures  technic  and  dexterity  are  necessary.  These 
can  be  acquired  only  by  practice,  a  thing  entirely  separate  and  apart 
from  the  knowledge  of  how  to  do  the  work.  To  make  manual  dexterity 
effective  one  must  acquire  the  ability  to  gauge  depth  and  to  recognize 
landmarks  with  the  use  of  one  eye  only,  and  must  further  have  a  clear 
concept  of  the  mechanical  problems  involved.  The  tubes  are  necessarily 
small,  especially  those  for  children,  and  the  surgeon  who  has  been 
accustomed  to  working  in  an  open  wound  with  both  hands  and  both 
eyes  will  find  himself  at  first  verv^  much  handicapped.  On  the  other 
hand  there  is  nothing  in  any  of  the  endoscopic  procedures  that  cannot 
be  safely  and  easily  done  by  anyone  who  will  devote  the  necessary 
time  to  practice.  No  amount  of  knowledge  will  lessen  the  necessity 
for  practice  with  the  eye  at  the  endoscopic  tube.  It  is  not  at  all  neces- 
sary that  this  practice  be  done  upon  a  patient.  The  eye  can  be  edu- 
cated by  the  use  of  a  bronchoscope  inserted  in  a  piece  of  rubber  tubing, 
the  other  end  of  which  is  fixed  by  having  a  weight  laid  upon  it  upon 
the  desk  or  table.  Foreign  bodies  can  be  inserted  in  the  rubber  tube, 
the  bronchoscope  passed,  and,  by  manipulation  of  the  foreign  body 
with  the  forceps,  the  eye  can  be  trained  not  only  in  the  intricate 
mechanical  problems  of  foreign-body  extraction,  but  the  experience 
acquired  will  facilitate  the  recognition  of  the  landmarks  in  introduction 
of  the  tubes,  and,  as  well,  aid  in  the  recognition  of  pathology.  It  is 
very  necessary  that  this  training  be  adequate  because  it  has  been  clearly 
proved  that  prolonged  endoscopic  procedures  are  dangerous  while  short 
ones  are  totally  free  from  mortality  if  carefully  done;  therefore  time- 
wasting  must  be  eliminated,  and  delay  minimized.    In  the  last  seven 

(735) 


736       LARYNGOSCOPY,   BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

hundred  cases  of  bronchoscopy  and  esophagoscopy  in  the  author's  cHnic 
no  death  has  resulted  from  the  insertion  of  the  endoscopic  tube. 

Instruments.— An  ordinary  working  outfit  does  not  contain  very 
many  instruments,  neither  are  these  very  complicated,  but  to  do  good 
work  it  is  absolutely  essential  that  the  outfit  be  adequate.  Many 
failures  and  much  mortality  have  resulted  from  inadequate  equip- 
ment. Different  sizes  are  necessary  for  adults  and  children.  Make- 
shifts are  impossible  because  of  the  limitations  imposed  upon  the  pro- 
cedure by  the  necessity  of  using  long  tubes  of  diameter  limited  by 
the  size  of  the  natural  passages.  Dilatation  of  the  natural  passages 
is  not  possible  here  as  it  is  in  the  urethra;  any  attempt  to  use  an  over- 
sized instrument  in  the  trachea,  bronchi  or  esophagus  is  very  quickly 
and  inevitably  fatal.  The  instruments  illustrated  in  Fig.  1  are  those  in 
common  use.  The  different  sizes  of  tubes  are  not  shown.  The  follow- 
ing is  a  list  of  an  ordinary  working  outfit: 

1  Jackson's  adult  laryngoscope. 

1  "         child  laryngoscope. 

1  "         infant  diagncstic  laryngoscope. 

1  "         anterior  commissure  laryngoscope. 

1  "         bronchoscope,       4  mm.  x  30  cm. 

1  "                       "5  mm.  X  30  cm. 

1  "                       "7  mm.  X  40  cm. 

1  "                       "9  mm.  X  40  cm. 

1  "         e-sophagoscope,     7  mm.  x  45  cm. 

1  "                       "               10  mm.  X  53  cm. 

1  "         side  grasping  forceps,  extra  light,  40  cm. 

1  "         forward  grasping  forceps,  regular,  50  cm. 

1  "         forward  grasping  forceps,  regular,  60  cm. 

6  "         light  applicators. 

1  "         aspirator  with  double  tube  for  minus  and  plus  pressure. 

1  "         aspirating  nozzle  for  mouth  .secretion. 

1  "         double  circuit  bronchoscopy  battery. 

4  Rubber  covered  conducting  cords  for  battery. 

1  Box  Jackson's  Bronchoscopic  sponges,  size    4. 

1  "              "                      "                     "        size    5. 

1  "             "                     "                    "       size    7. 

1  "             "                     "                    "       size  10. 

1  McKee-McCready  bite-block,  large  size. 

1  "                "                  "            small  si  e. 

1  Laryngeal  grasping  forceps. 

1  Dozen  extra  lamps  for  lighted  instruments. 

Anesthesia. — For  direct  laryngoscopy  in  children  no  anesthetic, 
general  or  local,  is  required  for  either  diagnosis  or  operation  upon  the 
larynx.  For  adults  local  anesthesia  may  be  obtained  by  painting  the 
interior  of  the  larynx  with  a  20  per  cent,  solution  of  cocain  and  if 
thought  advisable  the  reflexes  may  be  diminished  by  the  hypodermic 
injection  of  a  quarter  of  a  grain  of  morphin  about  an  hour  before 
operation.  Both  morphin  and  cocain  are  dangerous  in  children  and 
quit.e  unnecessary.  For  bronchoscopy  in  children  f no  anesthetic, 
general  or  local,  is  needed;  older  children  may  have  a'little  paregoric 
administered  if  considered  advisable  to  diminish  its  reflexes.  The 
inexperienced  operator  will  find  general  anesthesia  of  great  assistance 
to  him.  However,  the  matter  of  anesthesia  must  be  decided  on  the 
personal  equation  of  both  patient  and  operator.  It  is  for  the  latter  to 
decide  what  is  best  for  the  particular  patient   under  the  particular 


INSTRUMENTS 


737 


circumstances.  For  adults  morphin  hypodermically  to  diminish 
reflexes  and  cocain  locally  applied  with  the  sponge  holder  shown  at 
D,  Fig.  506  are  all  that  is  necessary.  Excessive  dosage  with  morphin 
or  other  antibechic  should  be  avoided,  especially  in  cases  with  much 
pus.  The  cough  reflex  is  the  watchdog  of  the  lungs  and  if  not  drugged 
asleep  may  be  relied  upon  to  rid  the  lungs  of  infective  material. 


Fig.  506. — Chevalier  Jackson's  instruments  for  direct  laryngoscopy,  bronchoscopy  and 
esophagoscopy:  A,  gastroscope  with  aspirator  attached;  B,  bronchoscope;  C,  aspirator 
with  negative  pressure  tube  attached  to  gastroscope.  Positive  pressure  tube  /;  D,  esoph- 
agoscope;  E,  laryngeal  cutting  forceps  for  taking  specimens;  F,  laryngeal  grasping  for- 
ceps; G,  adult  size  laryngoscope;  H,  bite-block;  I,  positive  pressure  tube  from  aspirator; 
/,  forceps  for  removing  foreign  bodies;  K,  sponge-carrier  for  sponging  the  field  and 
obtaining   specimens   of  secretion  from   the   bronchi. 


The  following  is  the  usual  method  of  applying  cocain  for  bronchos- 
copy in  adults:    Cocain  in  5  per  cent,  solution   is    applied    to_^the 


VOL.  I — 47 


738       LARYNGOSCOPY,   BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

pharynx  first  with  a  gauze  sponge  on  a  sponge-carrier  (C,  Fig.  50G). 
Then  after  introduction  of  the  laryngoscope  and  exposure  of  the  larynx 
the  interior  of  the  larynx  is  anesthetized  by  the  application  of  a  sponge- 
carrier  which  has  been  dipped  in  a  20  per  cent,  solution  of  cocain.  A 
deeper  application  of  the  same  strength  is  made  by  inserting  a  satu- 
rated sponge-carrier  through  the  glottis,  into  the  trachea  and  on  down 
to  the  bifurcation.  After  the  introduction  of  the  bronchoscope  the 
deeper  air-passages  and  the  various  bronchi  can  be  anesthetized  as 
deemed  necessary  by  painting  with  the  gauze  sponge  held  in  the 
sponge-carrier. 

Asepsis. — In  view  of  the  fact  that  the  peroral  endoscopist  encounters 
pneumonia,  diphtheria,  syphilis,  tuberculosis  and  various  pyogenic 
infections  it  is  wise  to  carry  out  every  detail  of  aseptic  operating-room 
technic  so  as  to  avoid  transferring  infection  from  one  patient  to  another. 
Even  the  mild  mouth  infections  to  which  a  particular  patient  has  be- 
come comparatively  immune,  may  be  very  virulent  when  transferred 
to  another  individual  who  has  not  a  relative  immunity  to  that  peculiar 
strain  of  perhaps  a  common  organism.  It  is  true  that  the  mouth 
cannot  be  rendered  aseptic;  but  oral  antisepsis  including  the  thorough 
cleansing  of  the  teeth  and  gargling  and  rinsing  the  mouth  with  20  per 
cent,  alcohol  will  minimize  septic  risks.  It  has  been  demonstrated  by 
the  author  that  the  bronchoscope  introduced  by  the  technic  herein 
described  is  practically  free  from  the  probability  of  carrying  infection 
to  the  deeper  air-passages. 

Position  of  the  Patient. — In  any  peroral  endoscopic  procedure  the 
position  of  the  patient  is  of  fundamental  importance.  The  patient  is 
recumbent  for  better  control  and  ease  of  manipulation  of  the  head  and 
shoulders.  For  direct  laryngoscopy  the  patient's  head  is  upon  the  table ; 
but  when  direct  laryngoscopy  is  done  as  a  preliminary  to  bronchoscopy 
the  patient's  head  and  shoulders  should  be  out  in  the  air  as  shown  in 
Fig.  507,  in  order  to  permit  of  free  motility  of  the  head  and  neck  in  every 
direction  as  required  in  the  exploration  of  the  deeper  air-  and  food- 
passages  with  a  straight  and  rigid  endoscopic  tube.  Some  extension 
of  the  head  is  necessary  to  move  the  upper  teeth  out  of  the  way  but  the 
extension  must  be  strictly  limited  to  the  occipito-atloid  joint.  If  the 
extension  includes  all  of  the  cervical  vertebrae  as  in  the  Rose  position, 
the  introduction  of  an  endoscopic  instrument  will  be  exceedingly 
difficult.  Another  important  difference  from  the  Rose  position  is  that 
for  endoscopy  it  is  essential  that  the  head  be  held  ver\'  high.  The 
occiput  should  be  higher  than  the  level  of  the  table  during  the  start  of 
introduction.  When  the  tube  has  reached  the  deeper  passages  the  head 
may  be  moved  in  any  direction  required  by  the  operator  who  is  follow- 
ing the  lumen  as  it  opens  up  ahead  of  the  endoscopic  tube.  The  posi- 
tion given  in  Fig.  507  has  been  worked  out  by  long  experience  to  facili- 
tate the  introduction  of  the  tube.  The  only  exception  to  this  position 
is  in  case  of  a  foreign  body  lodged  in  the  larynx  in  which  it  is  very  neces- 
sary to  avoid  the  dropping  of  the  intruder  into  the  deeper  air  passages 
in  case  the  foreign  body  should  be  dislodged  and  not  firmly  grasped. 
The  proper  position  for  such  cases  is  illustrated  in  Fig.  508. 


DIRECT  LARYNGOSCOPY 


739 


DIRECT  LARYNGOSCOPY. 

Direct  laryngoscopy  is  so  called  in  distinction  from  indirect  or  mirror 
laryngoscopy.  The  patient  being  in  the  position  shown  in  Fig.  507  (or 
in  case  of  foreign  body  in  the  larynx,  in  position  shown  in  Fig.  508)  the 
laryngoscope  is  grasped  in  the  left  hand  as  shown  in  Fig.  509.  The 
fingers  of  the  operator's  right  hand  are  used  to  draw  out  of  the  way  the 
upper  lip  of  the  patient  lest  the  upper  lip  get  pinched  between  the 
instrument  and  the  upper  teeth.  Such  an  accident  will  cause  the 
patient  exquisite  torture,  whereas  if  pinching  the  lip  be  avoided  there 


Fig.  507. — Direct  laryngoscopy,  recumbent  patient.  The  assistant  holding  the  head 
is  standing.  His  left  hand  is  producing  extension  on  the  occiputo-atloid  joint  and  at  the 
same  time  raising  the  occiput  above  the  level  of  the  table.  The  bite-block  is  inserted 
in  the  left  corner  of  the  mouth,  being  held  on  the  right  thumb  of  the  assistant,  the 
palm  of  the  hand  and  the  extended  fingers  resting  on  the  patient's  left  cheek  to  pre- 
vent rotation  of  the  head. 


is  nothing  in  the  other  part  of  the  procedure  that  will  be  painful.  The 
introduction  of  the  laryngoscope  and  the  exposure  of  the  larynx  may 
for  clearness  of  description  as  well  as  for  promptness  and  effectiveness 
of  execution  be  divided  into  two  stages: 

1.  Exposure  and  indentification  of  the  epiglottis. 

2.  Elevation  of  epiglottis  and  all  the  tissues  attached  to  the  hyoid 
bone  so  as  to  expose  the  larynx  to  direct  view. 

Stage  1. — ^The  patient  is  told  to  open  his  mouth,  or,  in  case  of  general 
anesthesia  the  mouth  is  opened  and  the  bite-block  {G,  Fig.  506)  inserted 
between  the  teeth  on  the  left  side  of  the  patient's  mouth.    The 


740       LARYNGOSCOPY,   BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


Fig.  508. — Author's  position  of  the  patient  for  the  removal  of  foreign  bodies  from  the 
larjnx  or  from  any  of  the  upper  air  or  food  passages.  If  dislodged,  the  intruder  will  nDt 
be  aided  by  gra\-ity  to  reach  a  deeper  lodgment. 


Fig.  509. — Direct  laryngoscopy,  recumbent  patient.  The  larjngoscope  is  held  in  the 
left  hand.  The  first,  second  and  third  fingers  of  the  right  hand  are  used  to  pull  down  the 
upper  lip  of  the  patient  to  prevent  pinching  the  lip  between  the  larj-ngoscope  and  the 
teeth.  The  camera  being  above  the  patient  gives  a  false  impression  of  the  position  of 
the  head  and  chest.     The  chest  is  really  verj'  much  lower  than  the  head. 


DIRECT  LARYNGOSCOPY  741 

laryngoscope  is  passed  into  the  patient's  mouth  along  the  right  border 
of  the  dorsum  of  the  tongue.  When  the  posterior  portion  of  the  tongue 
is  reached  the  spatular  tip  of  the  instrument  is  deviated  toward  the 
middle  line  so  as  to  expose  the  epiglottis  as  shown  at  A,  Fig.  510. 

Stage  2. — The  instrument  is  now  passed  about  1  cm.  deeper,  the 
spatular  tip  passing  posterior  to  the  epiglottis  and  immediately  a 
lifting  action  is  exerted  with  the  spatular  tip  as  if  the  effort  were  being 
made  to  suspend  the  head  by  lifting  upon  the  hyoid  bone  with  the 
spatular  tip  of  the  instrument.  If  the  larynx  is  not  at  once  exposed  it 
is  probable  that  the  instrument  has  been  inserted  too  deeply.  If  so  a 
slight  withdrawal  is  necessary  to  again  bring  the  epiglottis  into  view 
when  the  procedure  of  lifting  is  again  exerted.  Great  care  is  necessary 
to  avoid  the  great  natural  tendency  of  the  operator  unconsciously  to 
lower  his  head  and  to  get  lower  and  lower  himself.   This  must  resolutely 


Fig.  510. — Schema  illustrating  manner  of  exposure  of  the  larynx  with  the  direct  laryn- 
goscope. At  A  the  laryngoscope  has  been  inserted  posterior  to  the  dorsum  of  the  tongue 
until  the  epiglottis  has  come  into  view.  The  laryngoscope  is  then  inserted  about  1  cm. 
deeper,  the  spatular  tip  going  posterior  to  the  epiglottis.  A  strong  lifting  motion  is  now 
exerted  in  the  direction  of  the  dart,  even  lifting  the  patient's  head  from  the  table  as  shown 
at  B.  The  glottis  and  the  tracheal  axis  thus  are  brought  in  line  with  the  observer's 
visual  axis. 

be  resisted  and  the  object  always  kept  in  mind  of  lifting  the  patient's 
head  and  neck  upward  so  that  the  operator  can  see  into  the  larynx 
without  bending  over.  In  other  words  lifting  the  laryngoscope  up  to  a 
point  where  the  operator's  eye  can  see  through  it  into  the  larynx.  This 
is  necessary  to  avoid  the  fundamental  error  of  trying  to  pry  open  the 
larynx  by  using  the  upper  teeth  as  a  fulcrum.  When  the  larynx  first 
comes  into  view  the  cords  are  not  visible  because  of  the  spasmodic, 
tight  closure  of  the  ventricular  bands.  The  patient  is  told  to  take  a 
deep  breath.  As  soon  as  he  does  so  the  glottis  opens  and  the  cords  are 
visible  on  each  margin.  Of  course  if  the  patient  is  under  a  general 
anesthetic  he  cannot  be  told  to  take  a  deep  breath;  but  if  he  be  so 
deeply  anesthetized  that  the  reflexes  are  abolished  the  glottis  will 
remain  open  for  respiration. 

Removal  of  Foreign  Bodies  from  the  Larynx  by  Direct  Laryngoscopy. — 
Having  exposed  the  larynx  in  the  manner  described  the  foreign  body 
is  searched  for  and  when  found  the  portion  of  it  to  be  seized  is  deter- 


742       LARYNGOSCOPY,   BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

mined  according  to  the  size,  shape  and  surface  of  the  foreign  body. 
Pointed  foreign  bodies  should  ahvays  be  seized  at  or  as  close  to  the 
point  as  possible  and  the  point  is  then  freed  from  the  tissues  before 
removal.  In  the  case  of  transfixed  foreign  bodies  great  care  is  neces- 
sary not  to  lacerate  the  larynx  by  pulling  them  out  crosswise.  They 
should  be  seized,  as  in  the  case  of  pointed  foreign  bodies,  near  one  end 
if  neither  end  be  pointed.  Foreign  bodies  in  the  subglottic  space 
should  be  very  carefully  disimpacted  and  brought  out  with  their 
greatest  diameter  corresponding  to  the  sagittal  plane.  Great  care 
should  be  taken  not  to  lacerate  the  cords  and  not  to  injure  the  crico- 
arytenoid joint,  either  of  which  accidents  may  seriously  impair  the 
voice.  Severe  trauma  may  cause  edema,  later,  perichondritis,  either  of 
which  may  cause  so  much  stenosis  as  to  require  tracheotomy.  Care 
in  the  manipulations  will  avoid  such  complications. 

Direct  Laryngoscopy  for  the  Removal  of  Laryngeal  Growths  and  Specimens. 
— For  the  differential  diagnosis  of  diseases  of  the  larynx,  such  as  lues, 
malignancy  and  tuberculosis,  it  is  often  necessary  to  remove  a  specimen 
of  tissue  for  biopsy.  For  this  purpose  direct  laryngoscopy  is  invaluable 
because  of  the  accuracy  with  which  the  specimen  can  be  removed  from 
precisely  the  location  desired.  It  is  advisable  to  remove  the  margin 
of  the  growth  or  ulcer  so  as  to  include  a  small  portion  of  the  normal 
mucosa  in  order  that  the  histologist  may  see  the  transition.  If  the  case 
prove  to  be  one  of  malignancy  it  is  perhaps  not  so  serious  a  matter  if 
the  voice  be  impaired ;  but  if  the  case  should  prove  to  be  one  of  tuber- 
culosis or  lues  it  is  a  misfortune  to  have  injured  the  voice  by  damaging 
the  cords  or  the  motor  area  of  the  larynx.  Therefore,  whenever  pos- 
sible some  area  other  than  these  should  be  selected  for  the  removal  of 
the  specimen.  For  the  removal  of  specimens  the  cutting  forceps 
{E,  Fig.  506)  are  best. 

The  Removal  of  Benign  Growths  from  the  Larynx  by  Direct  Laryngos- 
copy.— Benign  growths  such  as  papillomata  can  be  removed  with 
great  accuracy  by  the  direct  method  and  such  removal  usually  results 
in  a  prompt  restoration  of  the  voice,  if,  as  is  usually  the  case,  the  growth 
has  been  interfering  with  clear  phonation.  The  best  forceps  for  this 
purpose  is  one  having  crushing  jaws  rather  than  cutting  jaws,  because 
the  papillomata  are  very  small,  resembling  venereal  warts  in  character. 
They  are  very  readily  crushed  off  and  the  difference  between  the  sound 
tissues  and  a  papilloma  is  very  promptly  noticed  by  the  trained  touch. 
Since  papillomata  are  very  prone  to  recur,  radical  operation  is  contra- 
indicated.  It  is  very  unwise  to  remove  the  base  deeply.  The  recurrence 
is  essentially  different  from  the  recurrence  of  malignancy.  Papillo- 
mata do  not  infiltrate  the  basal  tissues  and  very  often  a  "recurrence" 
is  in  the  form  of  an  entirely  new  growth  in  a  new  location.  No  matter 
how  radically  a  papillomatous  mass  may  have  been  removed  from  one 
cord  such  removal  can  in  no  way  prevent  recurrence  at  another  site,  for 
instance  the  opposite  ventricular  band,  and  to  have  damaged  the  cord 
by  radical  removal  of  the  base  is  a  great  and  avoidable  misfortune. 
The  best  ultimate  vocal  results  are  obtained  from  very  neatly  and 
precisely  removing  the  protruding  portion  of  the  papillomatous  mass 


BRONCHOSCOPY  743 

flush  with  the  surface  of  the  mucosa,  with  subsequent  removal  of 
"recurrences"  as  they  appear,  until  the  time  arrives  when  the  tendency 
to  recurrence  or  repullulation  ceases.  Ultimately  from  many  removals 
or  from  some  other  cause  the  tendency  to  recur  disappears.  Benign 
growths  other  than  papillomata  usually  do  not  recur,  after  complete 
and  precise  removal  by  direct  laryngoscopy. 

Direct  Laryngoscopy  for  the  Introduction  of  Intratracheal  Insufflation 
Anesthesia  Tubes. — The  insufflation  catheter  can  be  inserted  in  the 
trachea  by  anyone  who  will  take  the  time  to  practice  the  details 
mentioned  under  the  heading  of  Direct  Laryngoscopy.  The  catheter 
could  be  introduced  in  any  patient  without  any  anesthesia,  general  or 
local,  by  those  who  have  acquired  the  knack;  but  inasmuch  as  the 
patient  it  to  be  anesthetized  anyway  he  should  be  placed  deeply  under 
the  ether  by  the  open  method  before  any  attempt  is  made  to  insert 
the  insufflation  catheter.  This  abolishes  the  laryngeal  reflex  and  relaxes 
the  muscles  of  the  neck  in  a  way  that  makes  it  very  easy  to  expose  the 
larynx  if  the  anesthetist  follow  the  instructions  as  to  lifting  the  patient's 
head  off  of  the  table  by  the  hyoid  bone  with  the  tip  end  of  the  laryngo- 
scope passed  posteriorly  to  the  epiglottis  before  the  lifting  motion  is 
commenced,  as  seen  in  Fig.  510  and  Fig.  522.  The  following  rules 
should  be  carefully  observed: 

1.  The  patient  should  bs  fully  under  the  anesthetic  by  the  open 
method  so  as  to  get  full  relaxation  of  the  muscles  of  the  neck  and 
abolition  of  the  pharyngeal  and  laryngeal  reflexes. 

2.  The  patient's  head  must  be  in  full  extension  with  the  vertex 
firmly  pushed  down  toward  the  feet  of  the  patient,  so  as  to  throw  the 
neck  upward  and  bring  the  occiput  down  as  close  as  possible  beneath 
the  cervical  vertebra;  but  it  is  essential  to  remember  that  the  extension 
must  be  only  at  the  occipito-atloid  joint  and  that  the  patient's  head 
must  be  lifted  off  the  table.  Extension  with  the  head  lower  will  mean 
a  curvature  of  the  cervical  vertebra  which  will  defeat  the  object 
entirely.     The  head  must  be  high. 

3.  No  gag  should  be  used,  because  the  patient  should  be  sufficiently 
anesthetized  not  to  need  a  gag,  and  because  wide  gagging  defeats  the 
exposure  of  the  larynx  by  jamming  down  the  mandible  upon  the 
larynx. 

4.  The  epiglottis  must  be  identified  before  it  is  passed. 

5.  The  laryngoscope  must  pass  sufficiently  far  below  the  tip  of  the 
epiglottis  so  that  the  latter  will  not  slip  away. 

6.  Too  deep  insertion  must  be  avoided,  as  in  this  case  the  laryngo- 
scope goes  posterior  to  the  cricoid,  and  the  cricoid  is  lifted,  exposing  the 
mouth  of  the  esophagus,  which  is  bewildering  until  sufficient  education 
of  the  eye  enables  the  operator  to  recognize  the  landmarks. 

BRONCHOSCOPY. 

Introduction  of  the  Bronchoscope. — ^The  essentials  for  the  quick  and 
skilful  introduction  of  the  bronchoscope  are  two,  namely: 
1.  Adequate  exposure  of  the  glottis  by  direct  laryngoscopy. 


744      LARYNGOSCOPY,  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

2.  Correct  position  of  the  patient.  With  practice  it  should  not 
require  more  than  from  thirty  to  fifty  seconds  to  introduce  the  broncho- 
scope in  any  patient  whose  mouth  can  be  opened,  and  this  can  be  done 
in  children  without  any  anesthesia,  general  or  local.  In  adults  introduc- 
tion need  require  no  longer  except  for  the  time  required  for  the  painting 
on  of  a  local  anesthetic.  The  glottis  having  been  exposed  in  the  manner 
described  under  "  Direct  Laryngoscopy  "  the  bronchoscope,  illuminated 
with  its  own  separate  cord  from  the  bronchoscopic  battery,  is  intro- 


FiG.  511. — Schema  illustrating  the  introductior  of  the  bronchoscope  through  the  glottis, 
recumbent  putien'^.  The  handle,  H,  is  always  horizontally  to  the  right.  When  the  glottis 
is  fir.st  seen  through  the  tube  it  should  be  centrally  located  as  at  K.  At  the  next  inspira- 
tion the  end,  B,  is  moved  horizoptally  to  the  left  as  shown  by  the  dart,  M,  until  the 
glottis  shows  at  the  right  edge  of  the  field,  C.  This  means  that  the  point  of  the  lip,  B, 
is  at  the  median  line  and  it  is  then  quickly  (not  \'iolently)  pushed  through  into  the  trachea. 
At  this  same  moment  or  the  instant  before,  the  hyoid  bone  is  given  a  quick  additional  lift 
with  the  tip  of  the  laryngoscope  as  shown  by  the  dart  (Fig.  512).  In  the  sitting  patient 
everything  is  the  same  except  that  the  laryngeal  image  is  reversed  sagitally  and  laterally. 

duced  into  the  laryngoscope.  The  broncho  scop  ist's  eye  is  now  trans- 
ferred to  the  bronchoscope  and  the  glottis  found  again.  The  broncho- 
scope must  always  be  introduced  in  the  position  shown  in  Fig.  511,  the 
handle  being  out  to  the  right  as  shown  at  H.  As  soon  as  the  broncho- 
scopic tube  mouth  has  entered  the  trachea  care  is  taken  to  be  sure  that 
the  bronchoscope  is  introduced  not  farther  than  3  cm.  The  heavy 
laryngoscope  is  then  removed  by  axially  rotating  it  sidewise  and  remov- 
ing the  slide,  leaving  only  the  light  bronchoscopic  tube  in  position  as 
shown  in  Fig.  514.  Before  removing  the  laryngoscope  it  is  necessary  to 
be  certain  that  the  bronchoscope  is  in  the  trachea.  There  are  times 
when  the  bronchoscope  seems  to  have  a  tendency  to  slip  into  the 


Fig.  512. — The  operator  is  lifting  upward  strongly  with  the  laryngoscope  as  though 
suspending  the  head  and  neck  structures  by  the  hyoid  bone.  Care  should  be  taken 
not  to  use  the  teeth  as  a  fulcrum  and  try  to  expose  the  larynx  by  wedging  the  tip  of 
the  laryngoscope  upward.  The  bronchoscope  is  about  to  be  introduced.  Note  the 
position  of  the  handle  toward  the  right. 


Fig.  513. — Insertion  of  the  bronchoscope.  Note  direction  of  the  trachea  as  indicated 
by  the  bronchoscope.  The  patient's  head  is  held  above  the  level  of  the  table.  The  assist- 
ant's left  hand  should  be  at  the  patient's  mouth  holding  the  bite-block.  This  is  removed 
and  the  assistant  is  on  the  wrong  side  of  the  table  in  the  illustration  in  order  not  to  hide 
the  position  of  the  operator's  hands.  Note  the  handle  of  the  bronchoscope  is  to  the  right. 


746      LARYNGOSCOPY,  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

esophagus.  The  identification  of  the  trachea  is  very  readily  done  when 
the  trachea  is  not  inflamed  because  the  rings  show  out  clearly.  If  the 
mucosa  is  edematous  the  rings  may  be  obliterated.  A  strong  blast  of 
air  usually  comes  up  through  the  bronchoscope  in  an  unmistakable 
way,  but  it  must  be  remembered  that  the  bronchoscopist  may  be 
deceived  by  the  "breathing"  of  the  esophagus  apparent  when  a  tube 
is  inserted  in  it  owing  to  the  alternate  negative  pressure  during  inspir- 
ation. This  breathing,  however,  is  usually  associated  with  a  bubbling, 
spluttering  sound  that  is  unmistakable  once  it  is  heard.  One  of  the  most 


Fig.  514. — The  hea^T  larj'ngoscope  has  been  removed  leaving  the  light  bronchoscope 
in  position.  The  operator  is  inserting  forceps.  Note  how  the  left  hand  of  the  operator 
holds  the  tube  lightly  between  the  thumb  and  first  two  fingers  of  the  left  hand,  while 
the  last  two  fingers  are  hooked  over  the  upper  teeth  of  the  patient  "anchoring"  the  tube 
to  prevent  it  mo\-ing  in  or  out  or  otherwise  changing  the  relation  of  the  distal  tube- 
mouth  to  a  foreign  body  or  a  growi:h  while  forceps  are  being  used.  Thus,  also  any 
desired  location  of  the  tube  can  be  maintained  in  systematic  exploration.  The  assistant's 
left  hand  is  dropped  out  of  the  way  to  show  the  operator's  method.  The  assistant  during 
bronchoscopy  holds  the  bite-block  like  a  thimble  on  the  index  finger  of  the  left  hand,  and 
the  assistant  should  be  on  the  ri,:ht  side  of  the  patient.  He  is  here  put  wrongly  on  the 
left  side  so  as  not  to  hide  the  instruments  and  the  manner  of  holding  them. 

important  ways  to  identify  the  trachea  is  that  the  tube  stands  open 
whereas  the  esophageal  image  is  more  or  less  made  up  of  collapsing 
folds.  In  the  exploration  of  the  tracheobronchial  tree  the  next  land- 
mark is  the  bifurcation  of  the  trachea  which  is  located  by  "weaving" 
the  bronchoscope  from  side  to  side.  This  is  necessarj'  because  the 
bronchoscope  is  much  smaller  in  diameter  than  the  trachea.  If  it  were 
not  it  could  not  enter  either  bronchus.  Usually  it  is  better  to  have  the 
patient's  head  a  little  bit  to  the  right  and  the  handle,  H,  Fig.  511,  now 
turned  to  the  left.  This  brings  more  naturally  into  view  the  left  bronchial 


BRONCHOSCOPY  747 

orifice.  Needless  to  say  it  is  necessary  to  see  both  bronchial  orifices  in 
order  to  see  the  bifurcation  between  them  and  a  lost  carina  is  usually 
a  lost  left  bronchial  orifice,  because  morphologically  the  right  bronchus 
is  the  normal  continuation  of  the  trachea  and  the  bronchoscope  goes 
on  down  into  it  without  the  observer  having  seen  the  left  bronchial 
orifice  at  all,  unless  particularly  searched  for.  Having  located  the 
carina  the  right  upper  lobe  bronchus  is  next  exposed.  This  is  done 
not  by  deeper  insertion  of  the  bronchoscope  but  simply  by  the 
strong  swinging  of  the  head  to  the  left  with  the  bronchoscopic  tube- 
mouth  at  the  carina.  The  upper  lobe  bronchus  is  given  off  practically 
at  the  bifurcation  so  far  as  endoscopic  appearances  are  concerned. 
The  next  important  landmark  is  the  middle  lobe  bronchus  which  is 
seen  by  turning  the  handle,  H,  upward  so  as  to  bring  the  lip,  B,  up- 
ward, the  patient's  head  at  the  same  time  being  dropped.  This  brings 
into  view  the  anterior  wall  of  the  stem  bronchus.  The  middle  lobe 
bronchus  comes  ofl^  anteriorly  and  the  spur  between  the  middle  lobe 
bronchus  and  the  inferior  lobe  bronchus  is  a  horizontal  one.  The  stem 
bronchus  below  the  middle  lobe  bronchus  will  be  seen  to  give  off  dorsal 
and  ventral  as  well  as  lateral  branches.  Returning  to  the  carina  which 
is  our  first  landmark  in  the  lower  air-passages  the  bronchoscopic  lip  is 
turned  to  the  left,  the  patient's  head  moved  over  to  the  right  and  the 
bronchoscope  inserted  into  the  left  main  bronchus.  The  upper  lobe 
bronchus  in  the  adult  is  given  off  about  2  to  3  cm.  down  from  the  carina. 
The  orifice  is  exposed  by  strongly  bending  the  head  and  neck  of  the 
patient  to  the  right.  The  left  upper  lobe  bronchus  does  not  go  off 
directly  laterally  but  somewhat  anteriorly  so  that  the  spur  between  it 
and  the  orifice  of  the  inferior  lobe  bronchus  is  at  an  angle  of  about 
45  degrees  with  the  horizontal.  The  left  inferior  lobe  bronchus  gives 
off  dorsal  and  ventral  branches  very  similar  to  those  on  the  right  side 
except  for  the  one  large  posterior  branch  which  is  very  frequently 
invaded  by  foreign  bodies.  The  upper  lobe  bronchi  on  either  side 
cannot  be  entered  so  as  to  present  a  lumen  image.  Only  the  orifices 
and  a  small  portion  of  the  lumen  of  the  branch  bronchi  below  can  be 
seen.  The  main  portion  of  the  upper  lobe  bronchi  are  "around  the 
corner. "  Fortunately  they  are  exceedingly  rarely  invaded  by  foreign 
bodies;  otherwise  bronchoscopic  removal  would  be  not  so  uniformly 
successful. 

Bronchoscopy  for  Disease. — Lung  abscesses  can  be  entered  with  the 
bronchoscope  and  drained.  In  case  of  abscesses  secondary  to  foreign 
bodies  a  cure  results  almost  invariably  from  the  dilatation  of  the 
orifice  of  the  abscess  and  the  removal  of  the  foreign  body.  In  lung 
abscess  due  to  other  causes  bronchoscopy  has  so  little  to  offer  that 
external  operation  should  not  be  delayed.  Why  this  difference  should 
exist  remains  to  be  investigated.  Be  the  cause  what  it  may  there  can 
be  no  question  as  to  the  cHnical  facts.  Of  36  cases  of  lung  abscess 
secondary  to  foreign  body  in  the  author's  clinic,  34  are  alive  and  well 
today,  with  perfectly  normal  lungs  as  the  result  of  the  peroral  broncho- 
scopic removal  of  the  foreign  body.    Bronchiectasis  presents  almost  a 


748       LARYNGOSCOPY,   BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

parallel.  Bronchiectatic  conditions  not  due  to  foreign  body  have  been 
treated  by  endobronchial  lavage  and  local  medication  with  a  degree 
of  success  that  indicates  that  further  effort  in  this  direction  is  well 
worth  while.  On  the  other  hand  bronchiectatic  symptoms  secondary 
to  foreign  body  have  totally  disappeared  following  the  removal  of  the 
foreign  body,  in  every  case.^ 

While  the  removal  of  esophageal  secretion  is  readily  accomplished 
by  the  drainage  canal  and  negative  pressure  pump,  it  has  been  found 
that  bronchial  secretions  are  often  too  thick  and  viscid  to  pass  readily 
through  a  drainage  canal,  which  must  necessarily  be  small.  Because  of 
this,  the  sponge  pumping  system  was  evolved  by  the  author;  this 
consists  of  inserting  a  properly  sized  and  folded  gauze  sponge  on  a 
long  Coolidge  sponge-carrier  through  the  bronchoscope  so  that  it 
emerges  from  the  tube  mouth.  The  patient  is  then  asked  to  cough, 
following  which  the  sponge-carrier  is  withdrawn,  bringing  with  it  the 
secretion  which  the  patient  has  coughed  into  the  tube. 

Bronchoscopy  for  Foreign  Bodies. — The  introduction  of  the  broncho- 
scope may  be  very  quickly  mastered  by  anyone  who  cares  to  devote  the 
necessary  tune  to  the  manual  practice  of  the  details  of  introduction. 
When,  however,  we  come  to  the  mechanical  problems  of  the  with- 
drawal of  a  foreign  body  we  have  a  totally  different  matter.  The  most 
intricate  and  involved  mechanical  problems  may  try  to  the  utmost  the 
technical  and  especially  the  mechanical  skill  as  well  as  the  patience  of 
the  bronchoscopist.  It  is  only  by  the  greatest  carefulness  that  trauma 
can  be  prevented  and  it  is  only  by  the  manipulation  of  the  foreign 
body  in  such  a  way  that  points  will  not  become  entangled  in  branch 
bronchi  nor  buried  in  the  mucosal  wall  that  fatal  trauma  can  be  avoided. 
It  is  absolutely  unjustifiable  to  seize  and  grasp  any  portion  of  a  foreign 
body  as  soon  as  seen.  The  situation  of  the  intruder  must  be  studied 
and  the  proper  position  for  the  application  of  the  forceps  determined. 
All  of  this  must  be  done  without  delay  since  prolonged  bronchoscopies 
in  children  are  exceedingly  dangerous.  For  the  successful  solution  of 
these  complicated  mechanical  problems  it  is  absolutely  essential  that 
the  bronchoscopist  shall  practice  long  and  carefully  in  a  rubber  tube 
so  as  to  develop  to  the  utmost  the  fine  manual  skill  by  which  he  is 
able  to  execute  exceedingly  complicated  manipulations  by  coordinate 
control  of  the  lip  of  the  tube-mouth  and  the  forceps.  He  soon  acquires 
a  habit  of  using  these  together  just  as  one  uses  a  knife  and  fork.  He 
can  turn  a  foreign  body  around  end  for  end,  doing  a  "version;"  an 
unfavorable  presentation  can  be  converted  into  a  favorable  one  for 
seizure ;  the  lip  can  be  used  to  make  counterpressure  upon  the  tissues 
while  the  forceps  are  disembedding  the  point  of  a  foreign  body.  All 
of  these  procedures  can  be  done  with  perfect  safety  to  the  patient  pro- 
vided the  bronchoscopist  has  deemed  it  worth  while  to  practice  the 
procedures  and  provided  the  time  limit  of  the  first  bronchoscopy  is  not 
exceeded.    Even  the  specialist  in  bronchoscopy  does  not  get  sufficient 

1  Chevalier  Jackson:  Bronchiectasis  and  Bronchiectatic  Symptoms  Due  to  Foreign 
Bodies,  Penna.  Med.  Jour.,  August,  1916,  xix,  807-814. 


BRONCHOSCOPY 


749 


practice  upon  the  patient  because  his  bronchoscopies  in  each  case,  are 
generally  limited  to  the  few  minutes  usually  necessary  to  remove  the 


Fig.  515. — Schema  illustrating  the  mechanical  problem  of  extracting  a  pin,  a  large 
part  of  whose  shaft  is  buried  in  the  bronchial  wall,  B.  The  pin  must  be  pushed  downward 
and  if  the  orifice  of  the  branches,  C,  D,  are  too  small  to  admit  the  head  of  the  pin  some 
other  orifice  (as  at  A)  must  be  found  by  palpation  (not  by  violent  pushing)  to  admit  the 
head,  so  that  the  pin  can  be  pushed  downward  permitting  the  point  to  emerge  (E). 
The  point  is  then  manipulated  into  the  bronchoscopic  tube-mouth  by  means  of  coordi- 
nated movements  of  the  bronchoscopic  lip  and  the  side-curved  forceps,  as  shown  at  F. 


Fig.  516. — Schema  illustrating  the  "mushroom  anchor"  problem  of  the  brass-headed 
upholstery  tack.  At  A  the  tack  is  shown  with  the  head  bedded  in  swollen  muscosa. 
The  bronchoscopist,  looking  through  the  bronchoscope,  E,  considering  himself  lucky 
to  have  found  the  point  of  the  tack,  seizes  it  and  starts  to  withdraw  it,  making  traction 
as  shown  by  the  dart  in  drawing  B.  The  head  of  the  tack  catches  below  a  chondrial  ring 
and  rips  in,  tearing  its  way  through  the  bronchial  wall  (D)  causing  death  by  mediastinal 
emphysema.  This  accident  is  stUl  more  likely  to  occur  if,  as  often  happens,  the  tack- 
head  is  lodged  in  the  orifice  of  the  upper  lobe  bronchus,  F.  But  if  the  bronchoscopist 
swings  the  patient's  head  far  to  the  opposite  side  and  makes  axis-traction,  as  shown  at  C. 
the  head  of  the  tack  can  be  drawn  through  the  swollen  mucosa  without  anchoring  itself 
in  a  cartilage.  If  necessary,  in  addition,  the  lip  of  the  bronchoscope  can  be  used  to  repress 
the  angle,  K,  and  the  swollen  mucosa,  H.  If  the  swollen  mucosa,  H,  has  been  replaced 
by  fibrous  tissue  from  many  months'  sojourn  of  the  tack,  the  stenosis  many  require  dila- 
tation with  the  divulsor. 


foreign  body.  It  is  therefore  necessary  for  everyone  to  educate  the  eye 
and  the  fingers  by  work  with  the  bronchoscope   manipulating  and 


750       LARYNGOSCOPY,   BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

removing  a  foreign  body  previously  inserted  in  a  piece  of  rubber  tubing 
which  serves  as  a  manikin.    In  it  all  sorts  of  mechanical  problems  can 


ABC 

Fig.  517. — Problem  of  theupholstery  tack  with  buried  point.  If  puUei  upon,  the 
imminent  perforation  of  the  mediastinum,  as  shown  at  A,  will  be  completed,  the  bronchus 
will  be  torn  and  death  will  follow  even  if  the  tack  be  removed,  which  is  of  doubtful 
possibility.  The  proper  method  is  gently  to  close  the  side  curved  forceps  on  the  shank 
of  the  tack  near  the  head,  push  downward  as  shown  by  the  dart,  in  B,  until  the  point 
emerges.  Then  the  forceps  are  rotated  to  bring  the  point  of  the  tack  away  from  the  bron- 
chial wall.  It  is  usually  better  at  this  stage  to  release  the  tack  and  grasp  it  firmly  near 
the  point  for  withdrawal,  D.    During  stages  A,  B  and  C  the  tack  is  grasped  very  gently. 


Fig.  518. — Schema  illustrating  the  "upper-lobe-bronchus  problem,"  combined  with 
the  "mushroom-anchor"  problem  and  the  author's  well-tested  method  for  their  solu- 
tion. The  patient  being  recumbent,  the  bronchoscopist  looking  down  the  right  main 
bronchus,  M,  sees  the  point  of  the  tack  projecting  from  the  right  upper  lobe  bronchus, 
A.  He  seizes  the  point  with  the  side-curved  forceps  then  slides  down  the  bronchoscope 
to  the  position  shown  dotted  at  B.  Next  he  pushes  the  bronchoscopic  tube-mouth 
■  downward  and  medianward,  simultaneously  moving  the  patient's  head  to  the  right,  thus 
swinging  the  bronchoscopic  lever  on  its  fulcrum,  and  dragging  the  tack  downward  and 
inward  out  of  its  bed,  to  the  position,  D.  Traction,  as  shown  at  C,  will  then  safely  and 
easily  withdraw  the  tack.  A  very  small  bronchoscope  is  essential.  The  lip  of  the  bron- 
choscopic tube-mouth  must  be  used  to  pry  the  forceps  down  and  over,  and  the  lip  must 
be  brought  close  to  the  tack  just  before  the  prying-pushing  movement.  S,  right  stem- 
bronchus. 


be  simulated.    A  few  of  the  solutions  of  mechanical  problems  are  illus- 
trated in  Figs.  515  to  521  inclusive.^    In  all  of  these  manipulations 

1  For  further  study  of  this  subject  the  reader  is  referred  to  "Peroral  Endoscopy,"  text- 
book by  Chevalier  Jackson. 


BRONCHOSCOPY 


751 


A 


Fig.  519. — Schema  illustrating  the  endoscopic  closure  of  open  safety  pins  lodged  point 
upward.  The  closer  is  passed  down  under  ocular  control  until  the  ring,  R,  is  below  the 
pin.  The  ring  is  then  erected  to  the  position  shown  dotted  at  M,  by  moving  the  handle , 
H,  downward  to  L.  and  locking  it  there  with  the  latch,  Z.  The  fork.  A,  is  then  inserted 
and,  engaging  the  pin  at  the  spring  loop,  K,  the  pin  is  pushed  into  the  ring,  thus  closing 
the  pin.  Slight  rotation  of  the  pin  with  the  forceps  may  be  necessary  to  get  the  point 
into  the  keeper. 


Fig.  520. — Schema  illustrating  a  new  method  of  removal  of  bronchially-Iodged  staples 
or  double-pointed  tacks.  H,  bronchoscope.  A.  swollen  mucosa  covering  points  of  staple. 
At  E  the  staple  has  been  manipulated  upward  with  bronchoscopic  lip  and  hooks  until 
the  points  are  opposite  the  branch  bronchial  orifices,  B,  C.  Traction  being  made  in  the 
direction  of  the  dart  (F),  by  means  of  the  rotation  forceps,  and  counterpressure  being 
made  with  the  bronchoscopic  lip  on  the  points  of  the  staple,  the  points  enter  the  branch 
bronljhi  and  permit  the  staple  to  be  turned  over  and  removed  with  points  trailing  harm- 
lessly behind  (K). 


Fig.  521. — Schema  illustrating  the  use  of  the  lip  of  the  bronchoscope  in  disimpaction 
of  foreign  bodies.  A  and  B  show  an  annular  edema  above  the  foreign  body,  F.  At  C 
the  edematous  mucosa  is  being  repressed  by  the  lip  of  the  tube-mouth,  permitting  insinua- 
tion of  the  hook,  H,  past  one  side  of  the  foreign  body,  which  is  then  withdrawn  to  a  con- 
venient place  for  application  of  the  forceps.  This  repression  by  the  lip  is  often  used  for 
purposes  other  than  the  insertion  of  hooks.  The  lip  of  the  esophagoscope  can  be  used  in 
the  same  way. 


752       LARYNGOSCOPY,   BRONCHOSCOPY  AND   ESOPHAGOSCOPY 

it  is  necessary  to  keep  in  mind  that  if  no  harm  is  done  the  bronchoscopy 
can  be  repeated  any  number  of  times.  Therefore  it  is  absohitely  unjus- 
tifiable to  take  the  risk  of  liuUing  out  a  foreign  body  not  free  to  move 
and  from  which  the  tissues  cannot  be  protected  in  the  position  in  which 
it  is  found.  While  it  is  undoubtedly  true  that  if  allowed  to  remain  the 
foreign  body  will  prove  fatal  it  will  not  prove  fatal  within  weeks  or 
even  months.  Only  too  often  in  the  early  days  of  the  work  death 
promptly  followed  the  ruthless  tearing  out  of  an  entangled  foreign 
body  on  the  assumption  that  it  would  prove  fatal  if  allowed  to  remain. 
The  motto  should  be,  "Don't  kill  your  patient;  if  you  do  you  cannot 
try  again." 


Fig.  522. — Insufflation  ether  anesthesia  with  the  Elsberg  apparatus  in  the  clinic  of 
Dr.  Otto  C.  Gaub.  The  anesthetist,  Dr.  Wade  Elphinstone,  has  exposed  the  larynx  and 
is  about  to  introduce  the  silk  woven  catheter  in  a  case  of  head  surgery.  Note  the  full 
extension  with  the  head  on  the  table  and  the  relatively  high  position  of  the  head. 


Mortality  and  Results  of  Bronchoscopic  Foreign  Body  Extractions. — 
In  the  last  300  consecutive  cases  of  foreign  body  in  the  air-passages 
the  intruder  has  been  endoscopically  removed  bloodlessly  through 
the  mouth  in  98  per  cent,  of  the  cases.  There  has  been  no  death 
directly  attributable  to  the  endoscopic  procedure.  There  were  only 
three  deaths  from  any  cause  whatever  within  thirty  days  after  the 
bronchoscopy  and  this  included  cases  which  came  in  in  very  serious 
condition.  The  mere  passage  of  a  bronchoscope  is  unassociated 
with  any  mortality  if  considered  entirely  apart  from  the  condition  for 
which  it  is  done.  Undoubtedly  the  mortality  encountered  in  the  early 
days  of  the  work  was  due  to  failure  to  recognize  the  danger  of  prolonged 


BRONCHOSCOPY 


753 


« 


# 


I      ! 


^     %    I 


Fig.  523. — Foreign  bodies  removed  from  the  bronchi  bloodlessly  by  bronchoscopy  through 
the  mouth,  j  (A  few  specimens  from  the  author's  collection  of  753  foreign  bodies.) 


754       LARYNGOSCOPY,   BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

bronchoscopy  in  children.    The  duration  should  not  be  over  twenty 
minutes  in  a  child  under  one  year  of  age,  thirty  minutes  under  five 


Fig.   524. —  Case  No.  Fbdy.  619.     Radiograph  showing  safety  pin  very  low  in  left  lung 
of  a  girl  aged  fifteen  years. 

years  of  age.    Bronchoscopies  of  this  duration  can  be  repeated  once  a 
week  if  necessary  for  a  year  without  any  harm  to  the  patient  if  no 


Fig.  525. — Case  No.  Fbdy.  409.    Radiograph  showing  large  fence  staple  in  left  bronchus 
of  a  man  aged  forty-three  years.    Present  two  years. 


anesthetic  be  used,  and,  of  course,  if  the  utmost  gentleness  of  manipu- 
lation be  observed.    The  structures  are  tender  and  vital  and  anything 


BRONCHOSCOPY 


755 


like  heavy-handed  manipulation  may  be  fatal.     Overdistention  of   a 
bronchus  by  the  use  of  too  large  a  tube,  or  the  tearing  of  the  bronchial 


Fig.  526. — Case  No.  Fbdy.  440.  Lead  alloy  collar  button  in  left  lung  of  a  boy  aged 
fourteen  years.  Probable  sojourn  about  ten  years.  Note  extensive  pathologic  change 
in  left  lower  lobe.    Compensatory  emphysema  of  right  chest. 


Fig.  527. — Case  No.  Fbdy.  572.  Cap  off  brass  bedstead  in  the  right  bronchus  of  a  boy 
nine  years.    Probable  sojourn  about  two  years.    Note  dense  pathologic  shadow  in 
right  chest  and  compensatory  emphysema  in  left. 

wall  in  disentangling  a  foreign  body  may  result  in  death  within  a  few 
minutes  from  hemorrhage,  in  a  few  hours  from  mediastinal  emphysema 
or  in  a  few  days  from  septic  mediastinitis. 


756       LARYNGOSCOPY,   BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

Tracheotomic  Bronchoscopy. — In  the  early  days  of  the  development  of 
the  work  it  was  considered  necessary  in  many  cases  to  do  a  tracheotomy 
for  the  insertion  of  a  bronchoscopic  tube.  Development  of  an  improved 
technic  and  improved  armamentarium  have  rendered  the  tracheotomic 
route  obsolete.  There  is  absolutely  no  advantage  whatever  in  passing 
the  bronchoscope  through  a  wound  in  the  neck  as  compared  with 
passing  it  through  the  mouth.  If  anything  the  peroral  route  is  much 
more  favorable.  Of  course,  tracheotomy  may  be  required  for  dyspnea 
and  if  so  should  be  done,  but  in  such  a  case  the  subsequent  bronchos- 
copy should  be  done  through  the  mouth  and  not  through  the  tracheo- 
tomic wound.  Of  the  last  .300  cases  of  foreign  body  in  the  bronchi  in 
the  author's  clinic  the  294  foreign  bodies  that  have  been  removed  have 
been  taken  out  through  the  mouth. 

Fluoroscopic  Bronchoscopy. — Fluoroscopic  bronchoscopy  is  associated 
with  a  very  much  higher  mortality  than  ocularly  guided  bronchoscopy 
as  the  following  statistics  of  fluoroscopic  bronchoscopies  for  foreign 
bodies  by  various  operators  will  show: 

Foreign  body  removed  in  8  (66.7  per  cent.). 

Foreign  bodies  not  removed  4  (.33.3  per  cent.). 

Number  of  cases  fatal  within  a  week  5  (41.6  per  cent.). 

Of  fatal  cases  foreign  body  removed  in  3  (60  per  cent.). 

Of  fatal  cases  foreign  body  not  removed  in  2  (40  per  cent.) . 

From  the  foregoing  it  is  clear  that  fluoroscopic  bronchoscopy  because 
of  its  high  mortality  and  its  low  percentage  of  successes,  has  nothing  to 
justify  its  use  in  any  bronchially  lodged  foreign  body  case  until  after 
regular  ocularly  guided,  endoscopic  bronchoscopy  has  failed.  The 
only  cases  in  which  its  use  is  justifiable  are  those  in  which  a  small 
foreign  body  has  gone  far  out  to  the  periphery  because  of  its  small 
size  or  in  those  in  which  a  large  foreign  body  has  worked  its  way  out  to 
the  periphery  by  pathologic  processes.  In  such  cases  the  bronchos- 
copist  should  work  by  sight  through  the  tube  while  the  fluoroscopist 
tells  him  whether  he  should  search  farther  to  the  right  or  farther  to 
the  left,  anteriorly,  or  posteriorly  as  the  case  may  be. 

ESOPHAGOSCOPY. 

Introduction  of  the  Esophagoscope. — The  patient  should  be  in  the 
position  already  described  (see  Fig.  507).  It  may  be  well  here  to 
emphasize  again  the  fact  that  the  patient's  head  must  be  high  during 
the  first  stage  of  introduction. 

For  saf et}'  the  esophagoscope  must  be  passed  by  sight .  The  essentials 
of  the  author's  method  are  as  follow^s: 

1.  The  correct  "high-low"  position-sequence  of  the  patient. 

2.  A  knowledge  of  the  endoscopic  anatomy  in  the  living. 

3.  A  clear  conception  of  the  direction  and  changes  of  direction  of 
the  esophageal  axis  as  herein  given. 

4.  A  good  general  sense  of  direction  that  enables  the  endoscopist 
to  point  his  esophagoscope  in  the  general  direction  of  the  axis  of  the 
esophagus. 


ESOPHAGOSCOPY  757 

5.  A  clear  mental  image  of  the  esophagus  and  its  direction  in  relation 
to  the  esophagoscope. 

With  these  qualifications  the  endoscopist  has  only  to  follow  the 
landmarks  to  be  able  quickly  to  pass  the  esophagoscope  on  any  human 
being  whose  mouth  can  be  opened.  The  introduction  may  be  divided 
into  four  stages. 

1.  Entering  the  right  pyriform  sinus. 

2.  Passing  the  cricopharyngeus. 

3.  Passing  through  the  thoracic  esophagus. 

4.  Passing  the  hiatus. 

Stage  1 .  Entering  the  pyriform  sinus  is  readily  understood  by  look- 
ing at  the  schema,  Fig.  528.  The  aspirating  tube  being  attached  and 
the  esophagoscope  properly  illuminated,  the  collar  of  the  esophagoscope 
is  held  lightly  between  the  thumb  and  fingers  of  the  right  hand  while 
the  left  hand  rests  on  the  patient's  upper  jaw,  the  second  and  third 
fingers  being  inside  of  the  alveolus,  the  thumb  and  index  fingers  support- 
ing the  tube,  in  much  the  same  way  as  a  billiard  cue  is  handled.  In 
order  that  the  proximal  end  of  the  tube-mouth  shall  be  kept  very  high 


Fig.  528. — Schema  for  finding  the  pyriform  sinus  in  the  author's  method  of  esopha- 
goscopy.  The  large  circle  represents  the  cricoid  cartilage.  G,  glottic  chink,  spasmodically 
closed.  VB,  ventricular  band.  A,  right  arytenoid  eminence.  P,  right  pyriform  sinus, 
through  which  the  tube  is  passed  in  the  recumbent  posture.  The  pyriform  sinuses  are 
the  normal  food  passages. 

the  operator  is  standing  erect  with  his  eye  at  the  proximal  tube-mouth 
while  he  seeks  the  right  pyriform  sinus  (Fig.  528).  The  landmark  is 
the  right  arytenoid  eminence.  Great  care  must  be  taken  to  identify 
this  arytenoid  eminence.  Great  care  must  also  be  taken  to  avoid 
hooking  the  tube-mouth  over  this  eminence,  which  accident  would 
result  in  the  prevention  of  further  insertion  and  if  force  be  used  the 
arytenoid  motility  might  be  seriously  impaired.  Having  found  the  right 
arytenoid  the  tube  glides  in  readily  for  2  or  3  cm.  when  it  comes  to  a 
full  stop  and  the  lumen  disappears.  This  is  the  spasmodically  closed 
cricopharyngeal  constriction.  During  stage  1  or  any  of  the  stages 
the  fingers  are  not  inserted  in  the  mouth,  except  as  far  as  necessary  for 
the  hooking  of  the  phalanges  over  the  alveolus  in  order  to  get  anchorage 
for  the  tube,  as  shown  in  Fig.  529. 

Stage  2. — Passing  the  cricopharyngeus  is,  with  the  beginner,  the 
most  difficult  part  of  esophagoscopy,  especially  if  the  patient  is  unanes- 
thetized.  Local  anesthesia  does  not  help.  The  relaxation  of  deep 
anesthesia  does  help  very  greatly  but  it  does  not  seem  justifiable 
to  use  an  anesthetic  for  this  purpose  alone.     When  the  solid  firm 


758      LARYNGOSCOPY,  BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

resistance  of  the  cricopharyngeal  fold  is  felt,  force  must  not  be  used, 
only  a  steady  firm  pressure  should  be  made  on  the  esophagoscope 
while  a  strongly  anterior  (lifting  in  the  recumbent  position)  movement 
is  imparted  to  the  distal  end  of  the  esophagoscope  by  the  thumb  of  the 
left  hand,  support  of  which  is  afforded  by  the  second,  third  and  fourth 
fingers  inside  the  alveolus.  During  this  process  it  is  necessary  to  keep 
the  tube  very  high.  There  is  a  great  temptation  to  lower  the  proximal 
end  and  it  requires  firm  determination  on  the  part  of  the  esophagos- 
copist  to  resist  this  tendency.  At  the  same  time  the  lifting  motion  is 
imparted  with  the  thumb,  the  distal  end  of  the  esophagoscope  should 
be  guided  slightly  toward  the  middle  line  of  the  body  as  the  esophago- 


FiG.  529. — Esophagoscopy  by  the  author's  high-low  method.  First  stage.  Finding 
the  right  pjTiform  sinus.  In  this  and  the  second  stage  the  patient's  vertex  is  about 
15  cm.  above  the  level  of  the  table  and  in  full  extension. 


scope  is  lifted  over  (patient  recumbent)  the  fold  on  the  posterior 
pharyngo-esophageal  wall.  Alternate  pressing  and  releasing  will  not 
accomplish  the  result.  As  it  is  with  depressing  the  rebellious  tongue 
the  pressure  should  be  continuous,  not  intermittent;  finn  though  not 
forcible.  The  lumen  should  be  watched  for  anteriorly,  and  if  it  does 
not  quickly  appear  the  patient  should  be  told  to  take  a  deep  breath. 
A  little  patience  here  will  always  succeed.  It  is  very  essential  that 
the  handle  be  upward  toward  the  ceiUng  in  order  to  be  certain  that  the 
lip  of  the  esophagoscope  is  anterior.  The  manner  in  which  this  favors 
riding  up  over  the  obstruction  of  the  cricopharyngeal  fold  will  be  under- 
stood by  study  of  Fig.  530.  Perforation  is  most  apt  to  occur  at  the  weak 


ESOPHAGOSCOPY 


759 


point  in  the  esophageal  wall  between  the  oblique  and  orbicular  fibers 
of  the  inferior  constrictor.  This  is  the  same  weakly  supported  point 
through  which  the  esophageal  wall  herniates  in  the  genesis  of  a  diver- 
ticulum. After  passing  the  cricopharyngeal  fold  it  is  noted  that  the 
cervical  esophagus  presents  almost  no  resistance  to  the  tube. 


^ 


Fig.  530. — Schema  showing  how  the  tube-mouth  (A)  is  lifted  forward  to  raise  it  over 
the  cricopharyngeal  fold  (B)  as  the  latter  relaxes,  and  the  lumen  opens  up  at  the  top  of 
the  field  (C). 

An  alternative,  less  desirable  method  of  executing  stages  1  and  2,  is 
to  expose  the  pyriform  sinus  (Fig.  528)  with  the  laryngoscope  and  then 
to  pass  through  the  latter  a  suitable  esophagoscope,  'the  laryngoscope 
being  then  removed,  as  in  bronchoscopy.  A  small  esophagoscope  and 
a  large  laryngoscope  are  used. 


NECK. 

Fig.  531. — Schematic  illustration  of  the  author's  "high-low"  method  of  esophagoscopy. 
In  the  first  and  second  stages  the  patient's  head  fully  extended  is  held  high  so  as  to  bring 
it  in  line  with  the  thoracic  esophagus,  as  shown  above.  The  Roser  position  is  shown  by 
way  of  accentuation. 

Stage  3. — The  esophagoscope  usually  glides   easily  through  the 
thoracic  esophagus.    If  it  does  not  the  patient's  position  is  faulty  or 


760      LARYNGOSCOPY,   BRONCHOSCOPY  AND  ESOPHAGOSCOPY 

the  esophagoscope  is  being  fixed  by  friction  on  the  upper  teeth.  The 
lumen  of  the  esophagus  must  be  followed  very  carefully  and  very 
accurately  by  watching  it  open  up  ahead,  which  it  does  as  the  result  of 
negative  pressure  during  inspiration.  The  levels  of  the  aorta  and  left 
bronchus  are  readily  recognized  and  in  passing  them  the  lumen  of  the 
esophagus  seems  to  have  more  and  more  of  a  tendency  to  disappear 
anteriorly.  This  is  the  signal  for  lowering  the  head,  which  has  until 
now  been  kept  high.  (Note  the  schematic  illustrations.  Figs.  531 
and  533). 

Stage  4. — Passing  the  hiatus  is  very  easy  after  a  little  practice  if 
the  directions  here  given  are  followed.  The  direction  of  the  lower 
esophagus  is  anteriorly  and  to  the  left.  To  follow  this  direction  during 
esophagoscopy  upon  the  recumbent  patient  the  head  is  dropped  as 


Fig.  532. — Esophagoscopy  by  the  author's  "  high-low "  method.     Stage  4.     Passing  the 
hiatus.    The  patient's  vertex  is  about  5  cm.  below  the  top  of  the  table. 


shown  in  Figs.  532  and  533.  \^Tien  the  head  is  dropped  it  must  at  the 
same  time  be  moved  horizontally  to  the  right  in  order  that  the  axis 
of  the  esophagoscope  shall  correspond  to  the  axis  of  the  lower  third  of 
the  esophagus  which  deviates  to  the  left  so  that  the  tube  is  pointing 
in  the  general  direction  of  the  anterior  spine  of  the  left  ileum.  This 
brings  the  tube-mouth  quickly  to  the  hiatal  constriction  which  is  a 
spasmodically  closed,  rosette-  or  slit-like  orifice  due  to  the  contraction 
of  the  musculature  of  the  diaphragm  surrounding  the  esophagus  at  the 
hiatus  esophageus.  If  the  esophagus  is  normal  the  slit  is  very  readily 
found  and  gentle  but  firm  and  continuous  pressure  is  made  until  the 


ESOPHAGOSCOPY  761 

spasmodic  contraction  yields  and  the  esophagoscope  glides  quickly- 
through  the  abdominal  esophagus  the  length  of  which  is  approximately 
from  2  to  4  cm.  in  the  adult.  So  quickly  is  this  abdominal  esophagus 
passed  that  early  esophagoscopists  mistook  the  hiatal  opening  for  the 
cardia.  It  remained  for  the  author  to  demonstrate  the  error.  The 
author's  high-low  method  of  esophagoscopy  can  be  more  readily  under- 
stood by  the  schemse  Figs.  531  and  533.  It  is  in  the  perfecting  of  tfiis 
method  that  esophagoscopy  has  developed  from  a  slow  laborious 
uncertain  often  impossible  procedure  into  a  very  smooth  satisfactory 
technic  by  which  the  esophagoscope  can  be  passed  in  a  few  seconds  in 
any  patient  that  can  open  his  mouth,  provided  the  esophagus  is  per- 
vious. The  perfection  of  the  method  depends  upon  practice  and  upon 
the  position  of  the  patient  which  was  developed  by  Dr.  Boyce  in  con- 
junction with  the  author.    No  other  position  yields  the  same  freedom 


Fig.  533. — Schematic  illustration  of  the  author's  "high-low"  method  of  esophagoscopy, 
fourth  stage.  Passing  the  hiatus.  The  head  is  dropped  from  the  position  of  the  first 
and  second  stages,  CL,  to  the  position  T,  and  at  the  same  time  the  head  and  shoulders 
are  moved  to  the  right  (without  rotation)  which  gives  the  necessary  direction  for  passing 
the  hiatus.  , 

of  movement,  a  freedom  that  permits  the  patient  to  be  promptly 
moved  about  in  every  direction  in  order  that  the  operator  may  follow 
the  lumen.  Various  mechanical  methods  of  anchoring  and  fixing  the 
patients  have  been  advocated  but  all  of  them  are  a  hindrance  rather 
than  a  help  so  far  as  the  introduction  of  the  esophagoscope  is  con- 
cerned. Practice  upon  the  cadaver  under  the  tutelage  of  a  skilful 
instructor  is  really  necessary  to  learn  the  technic  and  the  landmarks, 
and  especially  to  learn  how  to  avoid  the  mortality  which  is  almost 
certain  to  follow  uninstructed  efforts  at  first  upon  the  living.  During 
esophagoscopy  the  aspirator  which  connects  with  the  drainage  tube  in 
the  wall  of  the  esophagoscope  keeps  the  field  free  from  secretions  which 
are  constantly  coming  up  from  the  stomach  no  matter  how  long  the 
patient  has  been  kept  without  food  or  water.  These  secretions,  being 
much  more  watery  than  those  of  the  bronchi,  are  readily  aspirated. 


762       LARYNGOSCOPY,   BRONCHOSCOPY  AND   ESOPHAGOSCOPY 

Esophagoscopy  for  Foreign  Bodies. — -AVhen  the  esophagoscope  reveals 
the  foreign  body  the  tube  is  stopped  at  once  and  fixed  against  the 
upper  teeth  by  means  of  the  finger  anchorage  already  referred  to  and 
illustrated  in  Figs.  514  and  532.   This  retains  the  esophagoscope  in  rela- 


-    —lo-cm 

Fig.  534. — Filiform  bougie  for  minute  cicatricial  strictures  of  the  esophagus.  The 
filiform  silk  woven  end,  .4,  is  joined  securely  to  a  spring  steel  shaft,  B,  thus  giving  all  the 
advantages  in  safety  of  a  silk  woven  bougie  at  the  tip  with  a  stiff  shank  that  enables 
the  bougie  to  be  carried  down  rigidly  through  the  length  of  the  esophagoscope.  Twelve 
sizes  are  made.  The  total  length  of  60  cm.  is  only  necessarj'  in  case  of  a  very  low 
stricture  in  an  adult.  For  use  in  children,  the  bougie  can  be  shortened  by  unscrewing. 
The  great  advantage  of  the  steel  shaft  over  any  sort  of  stylet  inserted  into  a  hollow 
filiform  is  that  the  small  diameter  of  the  steel  shank  permits  of  more  accurate  ocular 
guidance. 

tion  to  the  foreign  body.  The  anchorage  being  accomplished  with  the 
left  hand  the  right  is  free  to  take  the  forceps  which  are  applied  in  the 
direction  which  has  been  determined  by  the  previous  observation  of 
the  foreign  body  itself.  In  the  case  of  a  foreign  body  such  as  a  coin  or 
button  the  intruder  is  seized  flatwise  and  withdrawn,  care  being  taken 


Fig.  535. — The  problem  of  the  safety-pin.  Thiity-eight  safety-pins  have  been  endo- 
scopically  removed  from  the  larj'nx,  trachea,  bronchi  and  esophagus,  in  the  author's 
clinic,  by  this  and  other  peroral  endoscopic  methods. 

to  keep  its  plane  in  correspondence  with  the  lateral  plane  of  the  patient's 
body.  ^Vhen,  as  is  usually  the  case,  the  foreign  body  is  too  large  to 
come  through  the  esophagoscope,  the  intruder  is  held  closely  against 
the  tip  of  the  tube  mouth  while  forceps,  foreign  body  and  esophagoscope 


ESOPHAGOSCOPY 


763 


are  all  withdrawn  together,  their  mutual  relations  being  maintained 
by  fixing  the  forceps  against  the  proximal  tube-mouth.  If  the  foreign 
body  has  sharp  points  it  must  under  no  circumstances  be  pulled  upon 
until  the  relation  of  these  points  to  the  mucosa  is  determined  and  the 
foreign  body  allowed  to  rotate  into  such  a  position  that  the  esophageal 
wall  will  not  be  wounded.  Traumatic  esophagitis  is  almost  invariably 
fatal. 


Fig.  536. — Solution  of  the  mechanical  problem  of  the  button  or  other  disk-like  object 
with  a  sharp  point.  If  withdrawn  with  a  plain  forceps  applied  as  at  A,  the  point,  B,  will 
rip  open  the  esophageal  wall.  If  grasped  at  C,  the  point,  D,  will  rotate  in  the  direction 
of  F  and  will  trail  harmlessly  behind.  To  permit  rotation,  the  author's  rotation  forceps 
are  used  as  in  cross-section  at  H. 


Fig.  537. — Mechanical  spoon  for  short  esophagoscope.    A  longer  model  is  made  for  the 

esophagoscope. 

Safety-pins  may  be  closed  by  the  method  illustrated  in  Fig.  519,  or 
they  may  be  carefully  passed  down  into  the  stomach,  turned  and 
removed.  Still  another  method  is  shown  in  Fig.  535.  The  execution 
of  any  of  these  requires  a  great  deal  of  preliminary  practice  with  an 
esophagoscope  inserted  in  a  piece  of  rubber  tubing  in  which  a  safety- 


7G4       LARYNGOSCOPY,    BRONCHOSCOPY  AND  ESOPHAGOSCOPY 


Fig.  538. — Foreign  bodies  removed  from  the  esophagus  bloodlessly  by  esophagoscopy 

through  the  mouth. 


ESOPHAGOSCOPY  765 

pin  has  been  fixed  in  a  position  to  simulate  as  nearly  as  possible  a 
lodgment  in  the  esophagus. 

Buttons  which  have  a  sharp  point  are  removed  quickly  and  safely 
by  the  method  illustrated  in  Fig.  536.  Meat  and  other  soft  substances 
may  be  removed  readily  with  a  mechanical  spoon,  Fig.  537.  The 
author's  forceps  are  very  convenient  for  reaching  below  the  crico- 
phar^Tigeus  into  the  region  in  which  foreign  bodies  most  often  lodge 
in  the  esophagus. 

Esophagoscopy  for  Disease. — Cicatricial  stricture  of  the  esophagus 
is  very  safely  treated  by  means  of  the  filiform  bougies,  Fig.  534,  passed 
through  the  esophagoscope  by  sight.  The  usual  method  is  to  dilate 
the  esophagus  with  increasing  sizes  at  intervals  of  about  one  week,  no 
anesthetic,  general  or  local,  being  used.  The  method  is  vastly  safer 
than  any  form  of  divulsion  or  of  puUing  through  various  dilators  "^ith 
threads.  All  procedures  being  under  the  guidance  of  the  eye  no 
stretching  is  done  in  the  case  of  ulceration  which  is  a  very  frequent 
attendant  owing  to  stagnation  of  food  in  the  esophagus  above  the 
stricture.  Such  cases  are  treated  by  the  local  application  of  silver 
nitrate  or  arg\Tol  solutions  and  the  internal  administration  of  bismuth 
subnitrate  dry  on  the  tongue.  As  soon  as  the  ulceration  has  healed 
the  dilatation  is  proceeded  with,  the  result  being  a  cure  in  all  cases  in 
which  there  is  not  a  total  permanent  cicatricial  atresia. 

Esophagoscopy  for  Hiatal  Esophagismus  (So-called  "Cardiospasm,") — 
This  condition  is  very  readily  recognized  by  the  enormous  dilatation 
of  the  esophagus,  usually  filled  with  stale  food.  The  mucosa  is  coated 
with  a  white  pasty  adherent  material  which  is  A'ery  much  in  contrast 
with  the  pale  shining  pink  mucosa  of  the  normal  esophagus.  ^^Tien 
the  level  of  the  hiatus  is  reached  a  broad  floor  is  found  to  exist  in  the 
dilatation  and  in  this  floor  the  hiatus  must  be  searched  for.  It  will  be 
tightly,  spasmodically  closed  when  found,  but  gentle  pressure  continued 
without  intermission  will  cause  it  to  yield  and  the  esophagoscope  will 
readily  glide  into  the  stomach.  Esophagoscopy  with  a  large-sized 
esophagoscope  is  itself  a  very  efiicient  form  of  treatment.  If  it  fail  a 
mechanical  dilator  can  be  very  readily  used  through  the  esophagoscope 
with  excellent  results  and  with  perfect  safety  to  the  patient. 

Esophagoscopy  in  Malignant  Disease  of  the  Esophagus. — Esophagos- 
copy affords  the  only  means  of  making  a  very  early  diagnosis  of 
esophageal  cancer.  If  every  patient  who  has  the  slightest  sjTaptom 
referable  to  the  swallowing  function  were  esophagoscoped  esophageal 
cancer  could  be  discovered  very  early  and  the  diagnosis  could  be 
absolutely  determined  by  the  taking  of  a  specimen  with  the  forceps 
shown  at  E,  Fig.  506.  The  rapid  development  of  thoracic  surgery  ren- 
ders it  hopeful  that  the  early  diagnosis  will  enable  the  patient  to  obtain 
cure  by  external  operation.  Xo  endoesophageal  operation  seems 
justifiable.  Radiimi  can  be  applied  through  the  esophagoscope  and 
has  been  quite  efficient  in  retarding  the  progress  of  lesions  not  too  far 
advanced.  Large  lesions  are  probably  irritated.  The  malignantly 
stenosed  hmien  can  be  intubated  for  palliation  by  the  esophagoscopic 
piacement^of  a  silk-woven  Charters-SATnonds  tube. 


BRONCHOSCOPIC  AND  ESOPHAGOSCOPIC  VIEWS  SHOWING  THE  PATHO- 
LOGIC CHANGES  FOLLOWING  THE  PRESENCE  OF  FOREIGN 
BODIES  IN  THE  BRONCHI  AND  ESOPHAGUS.^ 

PLATE  XIII. 

Fig.  I. — Case  Fbdy.  616B.  Child,  aged  seven  years.  Steel  shawl-pin  with  head 
downward  to  left  in  left  upper-lobe  bronchus.  Point  Ijang  in  contact  with  median  wall 
of  left  main  bronchus.     Peroral  bronchoscopic  removal.     Cure. 

Fig.  2. — Case  269  P.  E.  Child,  aged  twelve  years.  Steel  shawl-pin  with  head  in 
left  upper-lobe  bronchus;  point  imbedded  in  median  wall  of  left  main  bronchus.  Endos- 
copic view  two  days  after  aspiration  of  pin.    Peroral  bronchoscopic  removal.    Cure. 

Fig.  3. — Case  Fbdy.  394B.  Infant,  aged  eighteen  months.  Steel  shawl-pin  with 
head  in  left  upper-lobe  bronchus;  point  imbedded  in  median  wall  of  left  main  bronchus. 
Pin  probably  in  situ  thirty-five  daj-s.  Inflammatory  state  obliterating  image  of  bronchial 
rings  due  to  two  previous  rough  bronchoscopies  by  an  operator  who  was  unable  to  see  the 
pin.  The  gra^-ish  patch  is  exudate  from  improper  instrumentation.  Ordinarily  reaction 
is  only  local  around  the  buried  point,  as  in  Fig.  2.  That  the  baby  sur\'ived  the  two 
pre\'ious  rough,  prolonged  bronchoscopies  is  remarkable.  Usually  such  work  is  fatal  to 
infants.  I  have  never  seen  such  a  reaction  from  either  a  metallic  foreign  body  or  a  care- 
fully done  bronchoscopy.     Peroral  bronchoscopic  removal.     Cure. 

Fig.  4. — Case  Fbdy.  577B.  Girl,  aged  seven  years.  Steel  shawl-pin  with  head  in 
left  upper-lobe  bronchus;  point  imbedded  in  median  wall  of  left  main  bronchus,  the  pin 
being  transfixed  across  the  lumen  of  the  bronchus.  Observed  fifteen  months  after  aspir- 
ation of  pin,  which  is  thickened  and  roughened  by  corrosion.  Inflammatory  state  less 
than  that  of  trauma  from  rough  bronchoscopy  in  case  shown  in  Fig.  3.  This  illustrates 
the  surprisingly  little  and  the  remarkably  limited  inflammation  .set  up  by  a  metallic 
foreign  body  in  the  bronchi.  It  is  only  in  the  immediate  neighborhood  that  the  rings  are 
obliterated  by  the  inflammation,  which,  moreover,  is  essentially  chronic.  Peroral 
bronchoscopic  removal.    Cure. 

Note.— Figs.  1,  2,  and  4  afford  a  noteworthy  opportunity  for  comparison  of  the  effect 
of  a  foreign  body  of  precisely  the  same  character  (steel  pins  with  glass  heads)  in  about 
the  same  location,  but  of  various  durations  of  sojourn. 

Fig.  5. — Case  Fbdy.  56.5.  Girl,  aged  eight  years.  Steel  shawl-pin  with  head  in  left 
main  bronchus,  the  point  in  tracheal  wall  above  orifice  of  right  bronchus.  A  tiny  stream 
of  blood  is  seen  to  be  carried  by  the  cilia  toward  the  posterior  wall  of  the  trachea.  (See 
also  Fig.   10.)     Peroral  bronchoscopic  removal.     Cure. 

Fig.  6. — Case  Fbdy.  625.  Man,  aged  twenty-one  years.  Dental  root-canal-reamer 
(tool  steel  with  brass  handle)  in  middle-lobe  bronchus,  the  point  ha^dng  entered  slightly 
into  the  mucosa.  Faint  areola  around  point  of  entrance.  (Compare  Fig.  11,  in  which  a 
similar  foreign  body  had  been  in  a  bronchus  for  three  months.)  Peroral  bronchoscopic 
removal.     Cure. 

Fig.  7. — Case  Fbdy.  569.  Woman,  aged  sixty-three  years.  Steel  shawl-pin  was 
aspirated  five  years  pre\dously,  and  probably  entered  a  branch  of  the  middle-lobe 
bronchus.  The  j'ellow  patch  on  the  mound-like  swelling  represents  a  mass  of  pus  and 
exudate. 

Fig.  8. — Same  case  as  in  Fig.  7.  The  pus  and  exudate  have  been  wiped  away,  reveal- 
ing the  end  of  the  much-corroded  pin  occupying  the  strictured  orifice  of  an  abscess  cavity. 
This  appearance  of  a  foreign-body  abscess  ca\'ity  is  not  unusual  but  the  mound-like 
protrusion  into  the  lumen  of  the  bronchus  is  rare. 

Fig.  9. — Same  case  as  in  Figs.  7  and  8.  Interior  of  abscess  cavity.  The  orifice  was 
dilated  and  the  pin  was  removed,  a  caisson-bronchoscope  has  been  inserted  and  the 
cavity  ballooned  for  examination  of  its  interior.  The  nature  of  the  band  stretching 
across  from  wall  to  wall  was  not  determined.  It  might  have  been  vascular,  bronchial  or 
cicatricial  tissue.  Pus  was  very  foul.  All  expectoration  ceased  after  a  few  weeks  and  the 
patient  is  still  well  at  end  of  two  years. 

Note. — Comparisons  of  Figs.  1,  2,  4,  7,  8  and  9  are  interesting  as  they  show  the  patho- 
logic changes  of  similar  foreign  Ijodies  (steel  pins  with  glass  heads),  present  for  various 
periods  from  two  days  to  five  years. 

Fig.  10. — Same  case  as  in  Fig.  5.  Tiny  stream  of  blood  is  seen  to  be  carried  by  the 
cilia  up  the  posterior  wall  of  the  trachea  and  out  the  "pitcher  mouth"  between  the 
arytenoids.  This  original  observation  of  the  author  has  been  observed  in  previous 
and  subsequent  foreign-body  cases.  Occasionally  it  is  seen  in  tuberculous  cases.  At 
intervals  the  cough  removed  the  streak  of  blood;  but  it  was  soon  replaced  in  cases  in 
which  the  bleeding  continued  in  sufficient  and  not  too  great  amount.  It  was  not  notice- 
able in  copious  hemorrhages. 

Fig.  11. — Case  Fbdy.  552.  Dental  root-canal-reamer  (tool  steel  with  brass  handle) 
in  left  upper-lobe  bronchus  for  three  months.  The  point  has  entered  the  wall  of  the  main 
bronchus,  the  point  of  entrance  being  surrounded  by  an  inflammatory  areola.     A  small 

>  Mutter  Lecture  1917,  in  Surg.,  Gynec,  and  Obst.,  March,  1919. 
(766) 


PLATE    XIII 


patch  of  exudate  is  adherent.  The  local  and  mild  character  of  the  inflammation  is  im- 
portant. Compare  Fig.  6,  which  shows  the  endoscopic  appearance  in  a  case  of  only 
two  daj^'  sojourn  of  a  similar  instrument. 

Fig.  12. — Case  230  P.  E.  Man,  aged  seventy-six  years.  Nickel-plated  brass  atomizer 
tip  in  right  stem  bronchus  ten  days.  Inflammatory  reaction  localized,  probably  because 
the  foreign  body  is  not  of  very  irritating  character  and  owing  to  the  hole  in  the  distal  end, 
it  does  not  obstruct  drainage.  Nickel-plating  tarnished  but  not  corroded.  Peroral 
bronchoscopic  removal.     Cure. 

Fig.  13. — Case  Fbdy.  611.  Man,  aged  fifty-eight  years.  Nickel-plated  brass 
atomizer  tip  in  right  stem  bronchus  one  and  one-half  years.  The  size,  shape  and  position 
of  this  foreign  body  are  precisely  the  same  as  in  the  preceding  case.  (See  Fig.  12,  above.) 
The  granulation  tissue  that  obstructs  the  view  into  the  interior  of  the  atomizer  tip  has 
developed  as  the  result  of  a  one  and  one-half  years'  sojourn.  The  granulations  surmount 
a  firm,  fibrous  stricture,  which  required  bronchoscopic  dilatation  for  the  removal  of  the 
foreign  body.  Pus  very  foul.  Perichondritis  present.  Nickelling  entirely  gone,  brass 
much  corroded.     Peroral  bronchoscopic  removal.     Cure. 

Note. — The  localized  character  of  the  inflammatory  processes  in  the  cases  illustrated 
in  Figs.  12  and  13,  is  noteworthy  and  is  probably  due  to  the  relatively  unirritating 
character  of  the  foreign  body  and  to  its  form,  which  because  of  the  opening  at  both  ends 
did  not  greatly  obstruct  drainage. 

Fig.  14. — Case  Fbdy.  572.  Boy,  aged  nine  years.  Brass  cap  from  bedstead  in  right 
main  bronchus  one  year  and  nine  months.  The  general  shape  and  position  of  the  foreign 
body  are  similar  to  Fig.  12;  but  there  is  no  hole  in  the  distal  end  of  the  cap.  The  obstruc- 
tion to  drainage  had  caused  much  more  extensive  pathology  in  the  right  lung  (shown  by 
roentgenography  and  physical  signs)  as  compared  to  the  two  preceding  cases.  Endo- 
scopically  the  bronchi  of  the  left  lung  were  normal,  and  this  was  corroborated  by  the 
ray  and  the  physical  signs,  both  the  two  last  indicating  compensatory  emphysema.  The 
illustration  shows  a  proximal  fibrous  stricture  covered  with  granulations.  The  pus  was 
copious  and  vety  foul.  Brass  much  corroded.  (See  radiograph.  Fig.  22.)  Peroral 
bronchoscopic  removal.     Cure. 

Fig.  15. — Case  Fbdy.  439b.  Boy,  aged  six  years.  Peanut  kernel  projecting  from 
the  orifice  of  the  right  upper-lobe  bronchus,  two  days  after  the  kernel  was  inhaled.  In- 
tense diffuse  bronchitis,  which  is  particularly  noteworthy  in  comparison  with  the 
relatively  mild  and  markedly  localized  inflammation  resulting  from  the  presence  of  foreign 
bodies  other  than  vegetable  substances  and  especiall  y  in  comparison  with  metallic  bodies, 
particularly  steel.     Peroral  bronchoscopic  removal.     Cure. 

Fig.  16. — Case  Fbdy.  584.  ChUd,  aged  five  years.  Peanut  kernels  in  middle-lobe 
bronchus  and  an  anterior  branch  of  the  inferior-lobe  bron'chus,  four  weeks  after  the 
accident.  Diffuse  bronchitis,  patches  of  exudate.  The  pus  which  was  copious  has  been 
sponged  away.  The  trachea  and  the  bronchi  of  the  other  lung  were  also  inflamed.  A 
younger  chUd  would  probably  have  succumbed  in  less  time.  Peroral  bronchoscopic 
removal.     Cure. 

Fig.  17. — Case  369  P.  E.  Man,  aged  twenty-three  years.  Bullet,  probably  chiefly 
lead,  in  orifice  of  left  bronchus.  Accidentally  inhaled  a  few  days  previously.  Localized 
bronchitis.    Lead  not  corroded.     Peroral  bronchoscopic  removal.     Cure. 

Fig.  18. — Case  Fbdy.  574.  Amalgam  tooth  filling,  probably  composed  of  silver,  tin 
and  mercury;  in  left  stem  bronchus  two  weeks.  Proximal  annular  edema,  possibly  due 
in  part  to  tight  impaction  of  the  foreign  body.  Localized  bronchitis.  Bronchi  of  the 
upper  lobe  and  of  the  other  lung  were  normal.  Peroral  bronchoscopic  dilatation  of 
annular  edema;  removal  of  foreign  body.     Cure. 

Fig.  19. — Case  Fbdy.  440.  Boy,  aged  fourteen  years.  Lead  alloy  collar  button 
in  left  inferior-lobe  bronchus  eleven  years.  Proximal,  firm,  fibrous  stricture,  covered 
with  granulations.  Bronchiectatic  cavity,  below,  lined  with  granulations,  and  filled 
with  very  foul  pus.  The  button  was  somewhat  corroded.  Stricture  dilated  and  foreign 
body  removed  by  peroral  bronchoscopy.     Cure. 

Fig.  20. — Case  243  P.  E.  Youth  of  eighteen  years.  Lead  alloy  collar  button  in  right 
lung  for  ten  years.  Cicatricial  web  occluding  half  of  bronchus.  At  bottom  of  dilated 
cavity  is  the  lumen  of  a  firm  fibrous  stricture.  The  foreign  body  was  found  immediately 
below  this  stricture  after  dilatation.  The  bronchiectatic  cavity  below  was  filled  with 
foul  pus.  It  seems  probable  that  originally  the  collar  button  had  remained  for  a  long  time 
at  the  location  of  the  web.    Peroral  bronchoscopic  removal  of  foreign  body.     Cure. 

Note. — Figs.  17,  19  and  20  afford  opportunity  for  comparison  of  the  effect  of  short  and 
prolonged  sojourn  of  lead  alloys  in  the  bronchi. 

Fig.  21. — Case  225  P.  E.  Boy,  aged  five  years.  Steel  nail  in  right  main  bronchus 
one  week.  Superficial  mild  bronchitis.  Nail  coated  thinly  with  film  of  corrosion.  Peroral 
bronchoscopic  removal.-    Cure. 

Fig.  22. — Case  Fbdy.  410.  Boy,  aged  eleven  years.  Steel  nail  in  right  stem  bron- 
chus nine  and  one-half  years.  Chronic  purulent  bronchitis  over  entire  right  lung.  Firm 
fibrous  stricture  of  very  small  lumen.  Granulations  and  very  foul  pus  filling  cavity  below 
stricture.  Nail  corroded  to  a  cinder-like  mass  that  pulled  apart  on  traction.  Peroral 
bronchoscopic  dilatation  of  stricture  and  piecemeal  removal  of  foreign  body.    Cure. 

(767) 


Fig.  23. — Case  Fbdy.  408.  Steel  nail  in  right  main  bronchus  about  three  years. 
Much  corroded  nail  clasped  tightly  in  a  bed  of  fibrous  tissue  and  granulations.  Pus 
very  foul.  Peroral  bronchoscopic  removal  of  nail.  Apparent  recovery,  followed  two 
months  later  by  death  from  purulent  process  in  lower  thorax  or  upper  abdomen.  Post- 
mortem unobtainable. 

Fig.  24. — Case  Fbdy.  621.  Girl,  aged  four  years.  Steel  nail  in  left  inferior-lobe 
bronchus  one  month.  Bronchitis  all  over  right  side  due  to  \'iolent  bronchoscopy  before 
admission.     Peroral  bronchoscopic  removal  of  nail.     Cure. 

Note. — Figs.  21,  22,  23  and  24  afford  opportunity  to  contrast  the  effects  of  steel  nail 
present  in  the  bronchi  for  periods  var^-ing  from  seven  days  to  nine  and  one-half  years. 

Fig.  25. — Case  Fbdy.  624.  Girl,  aged  four  years.  Pebble  in  right  main  bronchus 
three  days.  Proximal  annular  edema,  probably  from  pressure  of  tighly  impacted  smooth, 
round,  closely-fitting  body.  Localized  bronchitis.  In  a  previously  reported  case  of  a 
pebble  the  conditions  were  precisely  the  same.    Peroral  bronchoscopic  extraction.  Cure. 

Fig.  26. — Case  266,  P.  E.  Woman,  aged  twenty-three  years.  Brass  tag-fastener 
in  right  lung  seven  years.  Chronic  bronchitis.  Firm,  fibrous  stricture  of  stem  bronchus, 
with  slit-like  lumen,  below  orifice  of  middle-lobe  bronchus.  Very  foul  pus  was  coughed 
through  the  stricture.  A  large  ca\'ity  below  the  stricture  was  revealed  after  dilatation 
of  the  stricture.  The  foreign  body  was  located  at  the  top  of  the  cavity,  fixed  in  fibrous 
tissue.  Foreign  body  (brass)  corroded,  but  still  strong  after  seven  years'  sojourn. 
Extraction.    Cure. 

Fig.  27. — Case  244  P.  E.  Woman,  aged  forty-eight  years.  Glass  collar  button  in 
left  lung  for  twenty-six  years.  On  passing  bronchoscope  bronchus  was  found  completely 
occluded  by  fibrous  tissue.  This  was  excised  with  biting  forceps  used  through  the 
bronchoscope,  until  a  cavity  was  reached.  Across  the  neck  of  the  cavity,  the  collar 
button  was  found  fixed  in  fibrous  and  granulation  tissue,  as  here  shown.  The  cavity 
contained  very  foul  pus.  The  collar  button  was  removed  by  peroral  bronchoscopy  and 
patient  made  a  perfect  recovery. 

Fig.  28. — Case  233  P.  E.  Child,  aged  eleven  years.  Brass-headed  steel  tack  in  left 
upper-lobe  bronchus  four  days.  Slight  congestion  is  present  where  the  tack  rests  on  the 
spur  between  the  upper-lobe  and  stem  bronchi.  Slight  areola  of  inflammation  around  the 
buried  point  of  the  tack  on  the  inner  wall  of  the  main  bronchus.  Tack  not  visibly  cor- 
roded but  a  black  film  was  wiped  away  with  gauze.  Peroral  bronchoscopic  removal. 
Cure. 

Fig.  29. — Case  Fbdy.  382.  Youth,  aged  eighteen  years.  Brass-headed  steel  tack 
in  right  bronchus.  The  head  is  buried  in  granulation  tissue  in  the  stem  bronchus  below 
the  orifice  of  the  middle-lobe  bronchus;  the  point  is  buried  in  the  anterior  wall  of  the 
main  bronchus.  Pus  foul.  Localized  bronchitis.  The  middle-lobe  bronchus  is  relatively 
normal.  Small  amount  of  pus  was  found  in  uninvaded  lung,  probably  drawn  in  shortly 
before  bronchoscopy.     Peroral  bronchoscopic  removal  of  tack.     Cure. 

Fig.  30. — Case  Fbdy.  412.  Boy,  aged  six  years.  Brass-headed  steel  tack  in  right 
bronchus  two  and  one-half  months.  The  head  is  buried  in  granulation  tissue;  the  point 
has  ulcerated  outward  through  the  bronchial  wall;  but  this  occurred  so  slowly  that  the 
mediastinum  was  not  affected.  Bronchus  bronchiectatic  below  tack;  dilatation  filled 
with  foul  pus.    Large  area  of  "  drowned  lung. "    Peroral  bronchoscopic  removal.     Cure. 

Fig.  31. — Case  221  P.  E.  Woman,  aged  fifty-two  years.  Brass-headed  steel  tack  in 
left  lung  two  years.  Granulations  have  been  nipped  away,  revealing  the  point  of  the 
corroded  steel  shaft  of  the  tack  in  an  almost  closed  posterior  branch  of  the  inferior-lobe 
bronchus.     The  pus  was  very  foul.     Peroral  bronchoscopic  removal.     Cure. 

Note. — Figs.  28,  29,  30  and  31  afford  an  opportunity  to  contrast  the  pathologic 
changes  present  in  4  different  cases,  all  of  the  same  kind  of  a  foreign  body  in  the  bronchi 
for  periods  varjnng  from  four  days  to  two  years.  The  head  of  these  tacks  was  of  umbrella- 
like shape,  the  obstruction  by  which  would  vary  with  changes  of  position. 

PLATE  XIV. 

Fig.  1. — Case  Fbdy.  411.  Girl,  aged  seventeen  months.  Fishbones  in  right  stem 
bronchus  at  orifice  of  upper-lobe  bronchus  "many  days."  Intense  localized  bronchitis. 
Peroral  bronchoscopic  removal.     Cure. 

Fig.  2. — Case  308  P.  E.  Infant,  aged  nine  months.  Fish-bone  in  right  stem  bronchus 
twenty-nine  days.  Bronchitis  localized.  Orifice  of  right  upper-lobe  bronchus  normal. 
Peroral  bronchoscopic  removal.  Cure. 

Fig.  3. — Case  Fbdy.  386.  Woman,  aged  twenty-five  years.  Fishbones  in  branches 
of  left  inferior-lobe  bronchus  five  weeks.  Bronchitis  limited  to  invaded  branches  and 
their  orifices.  Proximal  portion  of  stem  bronchus  and  the  orifice  of  the  upper-lobe 
bronchus  are  seen  to  be  normal.     Peroral  bronchoscopic  removal.     Cure. 

Note. — Figs.  1,  2,  and  3  afford  opportunities  for  noting  the  effect  of  fishbones  in  the 
bronchi  for  considerable  periods. 

Fig.  4. — Case  Fbdy.  425.  Infant,  seventeen  months.  Walnut  kernel  in  orifice  of 
right  upper-lobe  bronchus  three  days.  Diffuse  tracheobronchitis.  Note  thickened 
(768) 


PLATE    XIV 


interorificial  spurs.     Severe  diffuse  bronchitis  was  present  in  left  lung  also.     Peroral 
bronchoscopic  removal.     Cure. 

Fig.  5. — Case  Fbdy.  550.  Boy,  aged  eleven  years.  Iron  casting  in  right  main 
bronchus  three  days.  Localized  bronchitis.  Left  bronchial  orifice  is  normal.  Peroral 
bronchoscopic  removal.     Cure. 

Fig.  6. — Case  Fbdy.  583.  Child,  aged  two  years.  Half  of  the  glass  eye  of  a  "teddy 
bear"  in  the  right  stem  bronchus  below  orifice  of  upper-lobe  bronchus  four  days.  Local- 
ized bronchitis.  The  main  bronchus  above  the  stem  bronchus  was  normal,  as  were  also 
all  the  bronchi  on  the  left  side.     Peroral  bronchoscopic  removal.    Cure. 

Fig.  7. — Case  Fbdy.  399.  Man,  aged  forty-four  years.  Galvanized  steel  staple 
(double-pointed)  in  a  dorsal  branch  of  the  right  inferior  lobe  bronchus  fifteen  days. 
Localized  inflammation.  Only  the  concavity  of  the  rounded  middle  portion  of  the  U- 
shaped  staple  is  visible.  The  points  are  toward  us,  buried  in  the  mucosa  by  coughing, 
and  hidden  by  the  annular  inflammatory  swelling.  The  orifice  of  the  middle-lobe 
bronchus  (above)  and  of  the  upper-lobe  bronchus  (to  the  right)  are  normal.  The  points 
of  the  staple  were  slowly  and  carefully  freed,  brought  upward  and  turned  down  into  the 
two  anterior-branch  orifices  seen  above  the  invaded  bronchus  to  permit  "version"  of 
the  staple  for  safe  removal,  which  was  followed  by  prompt  and  complete  recovery.  (See 
Journal  American  Medical  Association,  June  5,  1915,  p.  1906.) 

Fig.  8. — Case  Fbdy.  409.  Man,  aged  forty-three  years.  Large  fence  staple,  galva- 
nized steel,  in  left  main  bronchus  two  years.  Localized  bronchitis.  Acute  edema,  due 
to  efforts  at  bronchoscopic  removal  before  admission,  masks  the  chronic  lesions  some- 
what. Localized  bronchitis  and  perichondritis.  The  ring  of  reddish  tissue  hiding  the 
upward  projecting  points  is  fibrous  inflammatory  tissue,  much  firmer  than  the  acute 
edematous  ring  in  Fig.  7.  Vessels  are  visible.  There  were  granulations  deeper  down 
below  the  fibrous  ring,  where  the  staple  had  been  lying.  The  points  are  deeply  embedded 
by  prolonged  coughing  and  ulceration.  The  staple  was  removed  by  version,  the  points 
being  disembedded,  brought  upward  and  turned  down  into  the  right  bronchus,  whose 
orifice  is  shown  to  be  right.  The  limitation  of  the  inflammation  after  two  years  is  remark- 
able. The  carina  is  not  thickened  and  the  right  bronchial  orifice  is  normal.  Peroral 
bronchoscopic  removal.     Cure. 

Fig.  9. — Case  Fbdy.  622.  Postmortem  bronchoscopic  view  of  a  rubber  eraser  lying 
in  the  orifice  of  the  right  main  bronchus  seven  months.  The  carina  is  thickened.  The 
thin,  greenish,  flocculent  fluid  filled  both  lungs  and  the  trachea  up  to  the  larynx. 
The  view  represents  conditions  after  the  fluid  had  been  removed  sufficiently  partially  to 
expose  the  carina  and  the  rubber.  Both  lungs  were  functionally  destroyed  in  seven 
months. 

Fig.  10. — Case  Fbdy.  385.  Chicken-bone  lying  loose  at  the  orifice  of  a  bronchiec- 
tatic  cavity  as  seen  after  sponging.  Usually  foreign  bodies  of  prolonged  sojourn  are  fixed 
in  inflammatory  new  formation.  The  bone  had  been  in  the  lungs  about  a  year.  Peroral 
bronchoscopic  removal.     Cure. 

Fig.  11. — Man,  aged  thirty-seven  years.  Perichondritis  of  the  orifice  of  the  middle- 
lobe  bronchus.  Unhealed  cartilage  is  indicated  by  the  granulations  occupying  the  orifice 
of  an  anterior  branch  of  the  inferior-lobe  bronchus,  in  the  track  of  a  bullet  which  passed 
through  the  chest  thirteen  months  before.  This  shows  the  effect  of  trauma  without  the 
continued  presence  of  the  foreign  body  that  inflicted  it.  (Perichondritis  is  often 
present  in  cases  of  prolonged  sojourn  such  as  9,  14,  22,  etc.).  Rcovery  after  internal 
administration  of  small  doses  of  potassium  iodide  and  the  use  of  thromboiDlastin. 

Fig.  12. — Case  Fbdy.  623.  Man,  aged  thirty-nine  years.  Beef  bone  impacted  in 
right  main  bronchial  orifice  as  seen  twenty-three  days  after  aspiration.  Acute  localized 
bronchitis  due  to  rough  bronchoscopy  before  admission.  The  greenish  patch  of  exudate 
is  due  to  a  wound  made  in  a  bronchoscopic  attempt  to  remove  the  bone  before  admission.- 
The  left  bronchial  orifice  is  normal  and  the  carina  nearly  so.  Peroral  bronchoscopic 
removal.     Cure. 

Fig.  13. — Case  Fbdy.  310.  Woman,  aged  thirty-nine  years.  Chicken  bone  trans- 
fixed in  trachea.  Contrary  to  the  rule,  this  bone  is  in  the  lateral  plane.  The  bone  had 
been  in  the  trachea  six  days,  yet  the  reaction  is  limited  to  an  areola  around  the  points  of 
fixation.  This  is  in  marked  contrast  to  the  cases  of  prolonged  sojourn,  such  as  shown  in 
Figs.  10  and  14.     Peroral  bronchoscopic  removal.     Cure. 

Fig.  14. — Case  Fbdy.  608.  Man,  aged  twenty  years.  The  beef  bone  had  been  in 
the  lung  eleven  years.  It  is  shown  beyond  a  firm  fibrous  stricture  covered  with  granular 
inflammatory,  partly  epithelialized  tissue.  Perichondritis.  The  bone  in  its  crosswise 
diameter  is  larger  than  the  stricture  but  permitted  continuous  drainage,  at  both  sides, 
and  the  lumen  of  the  stricture  was  not  small,  which  probably  accounts  for  the  survival 
of  the  patient  for  so  many  years  in  spite  of  the  suppuration.  There  was  a  chronic  bron- 
chitis throughout  right  side.     Peroral  bronchoscopic  removal.     Cure. 

Fig.  15. — Case  Fbdy.  3676.  Boy,  aged  fourteen  years.  Deciduous  molar  tooth 
completely  obstructing  the  oriflce  of  right  upper-lobe  bronchus,  two  months  after  acci- 
dent. The  inflammatory  mass  in  which  the  tooth  was  embedded  is  thrown  into  promi- 
nence by  strong  lateral  pressure  with  the  lip  of  the  bronchoscope.  Distant  bronchi  and 
those  of  the  other  side  were  not  inflamed.  Peroral  bronchoscopic  extraction.  Cure. 
VOL.  I— 49  .  (769.) 


Fig.  16. — Case  Fbdy.  578.  Boy,  aged  three  and  one-half  years.  Ring  of  pearl  shell 
(mollusk)  in  esophagus  for  a  period  of  over  one  year.  Localized  chronic  esophagitis, 
ulceration;  swollen  folds.  Foreign  body  embedded  in  a  pocket  of  inflammatory  tissue, 
with  granulations  at  the  lateral  edges.  The  shell  had  whitish  incrustations  at  certain 
points,  but  whether  or  not  they  occurred  during  the  sojourn  in  the  esophagus  could  not 
be  determined.     Esophagoscopic   extraction.     Cure. 

Fig.  17. — Case  Fbdy.  431.  Boy,  aged  twelve  years.  Cockle  burr  in  larynx  one 
day.  Moderate  acute  laryngitis;  not  nearly  so  severe  as  one  would  anticipate  from  the 
prickly  nature  of  the  foreign  body.     Extraction.     Cure. 

Fig.  18. — Case  Fbdy.  432.  Girl,  aged  four  years.  Lead  alloy  image  of  a  hor.se  in 
the  larynx  more  than  one  month.  Larynx  swollen  almost  shut.  Granulations,  ulcer- 
ation. Tracheobronchitis  was  present  from  the  accumulation  of  secretions  due  to 
glottic  obstruction  and  loss  of  the  aid  of  glottic  movement  in  the  bechic  cycle.  Lead 
alloy  partly  covered  with  a  colored  varnish,  partly  not.  No  apparent  corrosion.  Direct 
laryngoscopic  removal.     Cure. 

Fig.  19. — Case  Fbdy.  364.  Boy,  aged  four  years.  Brass  safety  pin  in  larynx  more 
than  two  months.  Larynx  swollen  nearly  shut.  Glottic  margins  eroded.  Tracheo- 
bronchitis was  present  from  accumulation  of  secretions  that  could  not  be  expelled,  as  in 
preceding  case  (Fig.  18).    Brass  pin  blackened  by  corrosion.     Removal.     Cure. 

Fig.  20. — Case  Fbdy.  628.  Boy,  aged  twelve  years.  Coin  (silver  half-dollar)  in 
esophagus  five  days.  Slight  congestion  of  esophagus;  no  esophagitis.  The  silver  surface 
is  bright  at  the  sides  where  it  was  clasped  in  the  esophageal  folds.  The  vertical  central 
zone  on  all  surfaces  is  black  with  a  thick  dull  corrosion,  probably  sulphides.  Esophago- 
scopic removal.     Cure. 

Fig.  21. — Case  Fbdy.  426.  Nursing  infant,  girl,  aged  six  months.  Gold  "'filled" 
cuff-button  partly  in  trachea  and  partly  in  esophagus.  (See  Fig.  28).  Button  had  been 
swallowed  three  months  before  and  had  e^-idently  ulcerated  through  the  party  wall  into 
trachea,  the  large  part  of  the  button  being  in  the  esophagus,  the  stem  between  the  two 
parts  occupj-ing  a  fistula  through  the  party  wall.  Granulations  around  the  fistula.  Tra- 
cheobronchitis probably  from  mother's  milk  leaking  through  fistula  while  taking  breast. 
The  metal  was  corroded  in  patches.    Endoscopic  removal.    Cure. 

Fig.  22. — Case  Fbdy.  630.  Girl,  aged  twelve  years.  Shoe-button  (fiber  composition 
wdth  steel  eyelet)  in  left  stem  bronchus  seven  months.  Chronic  bronchitis  limited  to  left 
lower-lobe  bronchus.  Granulations  form  a  bed  for  the  button  and  obstruct  drainage. 
Some  degree  of  bronchiectasis  was  noticeable  below  the  button.  Fiber  unchanged,  steel 
eyelet   corroded.      Bronchoscopically   removed.      Cure. 

Fig.  23. — Case  Fbdy.  558.  Boy,  aged  about  two  years.  Cast-iron  "jack"  in 
esophagus  about  two  months.  Esophagitis,  inflammatorj'  infiltration,  granulations. 
(Compare  Fig.  30.)  The  cast-iron  was  not  corroded  in  the  slighest  degree  in  its  two 
months'  sojourn. 

Fig.  24. — Case  Fbdy.  434.  Woman,  aged  fifty-seven  years.  A  U-shaped  bit  of 
tinned  wire  from  an  eggbeater  in  the  esophagus  for  five  weeks.  The  only  inflammatory 
reaction  is  a  small  areola  around  the  location  where  the  two  sharp,  hook-shaped  points 
have  buried  themselves  in  the  mucosa.  The  wire  was  not  corroded  except  on  spots  where 
the  tinning  was  absent.     Esophagoscopic  removal.     Cure. 

Fig.  25. — Case  Fbdy.  358.  Girl,  aged  five  years.  Copper  (or  bronze)  halfpenny 
(British)  in  esophagus  twenty  hours.  No  local  reaction;  not  even  congestion.  (Compare 
Fig.  26).     Coin  not  corroded.     Esophagoscopic  removal.     Cure. 

J'ig.  26. — Case  Fbdy.  559.  Girl,  aged  four  and  one-half  years.  Copper  (or  bronze) 
halfpenny  (British)  in  esophagus  eight  months.  Granulation,  fibrous  narrowang,  swollen 
folds.  (Compare  Fig.  25.)  The  pennj^  was  very  much  corroded.  Esophagoscopic 
removal.     Cure. 

Fig.  27. — Case  Fbdy.  354.  Boy,  aged  two  and  one-half  years.  Gold  locket  in 
esophagus  thirty-six  hours.  No  inflammation  or  congestion.  No  corrosion.  Esophago- 
scopic removal.     Cure. 

Fig.  28. — Same  case  as  shown  in  Fig.  21.  The  large  end  of  the  cuff-button  is  here 
shown  as  seen  in  the  esophagus,  the  .stem  disappearing  in  the  anterior  wall  occupies  a 
fistula  leading  into  the  trachea.  There  is  a  moderate  esophagitis  with  swollen  folds  and 
rough  granular  mucosa.     Peroral  endoscopic  removal.     Cure. 

Fig.  29. — Case  Fbdy.  590.  Girl,  infant,  aged  nine  months.  Wool  from  a  blanket 
in  esophagus  many  days.  No  esophagitis.  Mucosa  not  reddened.  (Patient  a  nursling 
and  very  anemic.)  Below  the  wool  there  was  a  mild  esophagitis  surrounding  three  other 
foreign  bodies;  namely,  a  fragment  of  a  button,  a  cherry  pit,  and  a  mass  of  cotton-wool. 
All  were  extracted  by  esophagoscopy.     Recovery. 

Fig.  30. — Case  234  P.  E.  Infant,  eleven  months  old.  Cast-iron  "jack"  in  esophagus 
two  weeks.  No  esophagitis.  Slight  congestion.  (Compare  Fig.  23.)  No  corrosion  of  the 
cast-iron.     Esophagoscopic  extraction.     Cure. 

Fig.   31. — Case  93.    Boy,  aged  three  years.    Probang  bristles  in  esophagus  seven  days. 
Intense  esophagitis  due  to  use  of  probang  before  admission.     To  the  right  are  seen  two 
linear  abrasions  covered  with  exudate.     Esophagoscopic  removal.     Cure. 
(770) 


SUEGICAL  DISEASES  OF  THE  THYfiOID 
AND  PARATHYEOID  GLANDS. 

By  nelson  M.  PERCY,  M.D. 

GOITER. 

In  reviewing  the  literature  on  the  subject  of  goiter,  one  is  immediately 
impressed  with  the  great  number  of  articles  which  have  been  written 
within  the  past  few  years.  Very  often  the  literature  is  so  contradictory, 
that  if  one  were  to  balance  the  views  of  the  many  observers  the  result 
would  be  almost  ?iil.  This  observation  alone  is  sufficient  to  acquaint 
one  with  the  fact  that  our  scientific  knowledge  of  goiter  is  yet  very 
limited.  For  this  reason  it  is  the  plan  of  the  author  to  state  only 
those  facts  which  have  been  proved  by  well-known  methods,  or  those 
theories  which  apparently  corroborate  the  clinical  findings  in  our  cases 
of  goiter. 

The  clinical  history  of  goiter  dates  back  nearly  a  century  and  a  half 
when  in  1786.  Parry ^  described  the  condition  known  as  exophthalmic 
goiter.  The  surgical  history  of  goiter,  however,  was  very  meager  until 
the  last  quarter  of  the  nineteenth  century,  when  Kocher  attracted  great 
attention  by  his  practical  demonstration  in  hundreds  of  cases,  that 
th\Toidectomy,  if  skilfully  performed,  was  a  comparatively  safe  opera- 
tion and  not  as  dangerous  a  procedure  as  the  earlier  surgeons  had 
thought. 

Moebius,^  in  1886,  added  a  very  important  element  to  the  surgical 
treatment  of  exophthalmic  goiter,  when  he  demonstrated,  quite  con- 
clusively, that  in  this  disease  there  is  an  absorption  of  some  toxic 
substance  secreted  by  a  diseased  thyroid  gland  which  enters  the  general 
circulation  through  the  lymphatic  system.  There  is  no  doubt  but  that 
the  surgical  work  of  Kocher  in  simple  goiter,  and  the  physiological  and 
pathological  explanation  of  Moebius  in  exophthalmic  goiter,  has  much 
to  do  with  establishing  the  surgical  treatment  of  exophthalmic  goiter. 

In  the  year  1835  Graves,^  in  his  course  of  lectures,  which  were  pub- 
lished in  1843,  described  the  disease  now  known  as  exophthalmic  goiter 
so  clearly  that  it  became  known  as  Graves's  disease  by  all  English- 
speaking  physicians. 

In  1840  von  Basedow*  described  the  same  disease  in  Germany,  from 
which  source  it  derived  the  name  of  Basedow's  disease. 

1  Quoted  by  Ochsner  and  Thompson,  "Thyroid  and  Parathyroid  Glands,  1910. 

2  Schmidt's  Jahrb.  d.  in.  und  aus.  gesamt.  Med.,  1886. 

3  System  of  Clinical  Medicine,  Dublin,  1843. 

4  Casp.  Wchnschr.  f.  d.  ges.  Heilk.,  1840. 

(771) 


772     DISEASES  OF   THE  THYROID  AND  PARATHYROID  GLANDS 

The  condition  known  as  myxedema  was  described  by  Gull  in  1873. 
In  1882  Kocher  established  the  fact  that  when  the  entire  thyroid 
gland  was  removed,  myxedema  developed,  hence  his  introduction  of 
the  term  cachexia  strumipriva.  The  most  important  historical  data  is 
that  of  Moebius,  when,  in  1886,  he  established  the  fact  that  exoph- 
thalmic goiter  was  due  to  some  toxic  substance  in  the  circulation  from 
a  pathological  activity  of  the  thjToid  gland.  IMoebius'  theory  is  quite 
generally  accepted  today,  and  has  been  proved,  from  the  surgical  stand- 
point, by  the  cure  of  many  patients  suffering  from  exophthalmic  goiter 
whenever  the  diseased  portion  of  the  thjToid  gland  had  been  removed. 

The  development  of  a  safe  and  satisfactory  surgical  management  of 
goiter  belongs  to  our  contemporary  surgeons,  much  of  which  has  come 
from  the  works  of  C.  H.  ]\Iayo,  Ochsner  and  Crile. 

Etiology. — Goiter,  in  the  various  forms,  is  found  in  all  countries, 
regardless  of  race,  but  is  more  prevalent  in  Europe,  Asia  and  North 
and  South  America.  In  North  America  enlargement  of  the  thyroid 
does  not  occur  endemically  to  any  appreciable  extent,  neither  have  any 
epidemics  occurred  such  as  have  been  reported  in  Europe. 

In  chronic  types  of  goiter  the  drinking  water  probably  plays  an 
important  role.  Kocher  found  in  the  Canton  of  Berne,  Switzerland, 
that  there  were  what  might  be  termed  goiter  fountains,  because  these 
waters  almost  invariably  produced  goiter  in  children  who  drank  it. 
On  the  other  hand,  people  who  lived  in  the  same  district  but  received 
their  water  supply  from  elsewhere  did  not  develop  the  di^ase.  Wilms,^ 
in  a  series  of  experiments  upon  dogs,  monkeys,  rats  and  guinea-pigs, 
found  that  enlargement  of  the  thjToid  followed  regularly  after  ingestion 
of  water  from  certain  springs  in  regions  where  goiter  was  endemic. 
Goiter  also  developed  in  the  animals  when  the  residuum  after  filtra- 
tion of  such  water  was  added  to  w^ater  from  springs  in  other  regions  free 
from  goiter.  Bircher^  also  carried  on  similar  experiments  and  caused 
struma  in  rats  by  causing  them  to  drink  water  of  the  particular  geo- 
graphical sources  that  are  known  to  cause  it  in  human  beings.  His 
series  embraced  120  animals,  was  carefully  controlled  and  consisted 
of  animals  from  various  districts.  Against  the  120  successful  attempts 
in  producing  goiter,  there  was  not  a  single  tumor  found  in  the  control 
animals.  Balfour,^  in  his  study  of  patients  with  goiter  who  have  come 
to  the  INIayo  Clinic,  made  a  careful  routine  inquiry  into  the  environ- 
ment of  the  individuals,  particularly  with  reference  to  the  water  supply 
during  their  entire  lives,  and  found  nothing  suggestive  of  any  relation- 
ship to  water  as  an  etiological  factor  in  the  production  of  this  disease. 

Modern  evidence,  however,  seems  clearly  to  show  that  certain  agents 
ingested  through  the  intermediary  of  water  may  cause  the  disease, 
and  that  there  are  certain  districts  in  which  endemic  goiter  is  due  to 
some  water-borne  agent.  There  are  different  theories  as  to  the  nature 
of  this  agent,  one  being  that  there  is  some  substance  in  the  drinking 

1  Deutsch.  Ztschr.  f.  Chir.,  January,  1910. 

2  Ibid.,  1911,  Bd.  cxii,  Nos.  4-6. 
5  Mayo  Clinic,  1914,  vol.  vi. 


GOITER  773 

water,  or  in  excess  in  the  water,  causing  goiter,  as  in  Europe,  the 
geological  formation  of  many  of  the  affected  districts  contained  vast 
masses  of  limestone.  McLelland,i  for  example,  found  that  50  per  cent, 
of  persons  living  in  certain  limestone  districts  in  India  had  goiter,  while 
in  only  1  per  cent.,  or  even  0.5  per  cent.,  did  it  occur  in  non-limestone 
districts. 

Kocher  has  maintained  for  some  time  that  the  prevalence  of  goiter 
depended  upon  the  amount  of  organic  matter  in  water  rather  than 
upon  the  water  itself,  the  real  exciting  cause  being  a  pathogenic  organ- 
ism or  the  toxin  from  such.  The  fact  that  by  experimental  work  it  was 
found  that  water  which  regularly  produced  goiter,  failed  to  produce  the 
disease  after  it  had  been  boiled,  would  tend  to  substantiate  the  above 
theory. 

McGarrison,2  after  extensive  experiments  believes,  that  the  etio- 
logical factor  in  endemic  goiter,  is  infection  from  the  gastro-intestinal 
tract,  although  as  yet  he  has  not  been  able  to  isolate  the  specific  toxic 
agent.  Some  of  his  conclusions  are :  Goiter  is  caused  by  an  organism 
invading  the  body  of  man.  All  the  evidence  points  to  the  intestine 
as  the  seat  of  infection.  In  nature  it  lives  in  the  soil  of  infected  locali- 
ties. It  is  carried  to  man  in  the  drinking  water  by  contact  with  the 
soil  or  by  other  means  yet  unknown.  The  virus  is  given  by  persons 
suffering  from  goiter,  in  some  way  as  yet  undetermined,  but  most 
likely  by  means  of  the  feces.  He  has  been  able  to  cause  goiters  to 
disappear  entirely  by  the  use  of  vaccines  prepared  from  the  normal 
bacteria  inhabitmg  the  intestmal  canal.  In  this  connection  it  is  inter- 
esting to  note  that  Sir  Arbuthnot  Lane^  believes  that  all  goiters  are 
due  to  auto-intoxication  from  the  uitestinal  canal,  and  reports  cures 
in  both  simple  and  exophthabnic  cases  following  short-circuit  operation 
upon  the  colon. 

In  our  own  series  of  cases  there  have  been  a  number  of  cases  in  which 
all  the  children  in  a  family  remained  free  from  goiter  until  the  family 
took  up  its  abode  on  a  new  farm,  when  all  of  the  younger  children 
developed  goiter,  while  those  who  were  born  after  a  subsequent  change 
of  location  again  remained  free. 

The  observations  of  Bircher  in  Rapperswyl,  Switzerland,  are,  how- 
ever, most  striking.  More  than  70  per  cent,  of  all  children  born  and 
raised  in  the  village  developed  goiter  while  the  original  water-supply 
was  in  use,  while  of  those  born  since  the  introduction  of  the  new  w^ater- 
supply  almost  none  have  developed  goiter.  The  original  water  supply 
was  taken  from  one  side  of  the  valley  where  the  land  had  been  sub- 
merged in  past  ages,  while  the  opposite  side  of  the  hill  was  composed 
of  granite  rock. 

Classification  of  Goiter.^The  reason  so  many  classifications  of  goiter 
have  been  advanced  is  that  there  has  not  heretofore  been  found, 
between  clinical  symptoms  and  pathological  findings,  a  definite  and 

1  Quoted  by  Berry,  British  Med.  Jour.,  April  14,  1906. 

2  Lancet,  January  25,  1913. 

3  British  Med.  Jour.,  1913,  i,  1125. 


774     DISEASES  OF   THE   THYROID  AND  PARATHYROID  GLANDS 

constant  relation  that  is  satisfactory  to  a  majority  of  workers.  It  was 
for  this  reason  that  MacCarty^  recently  made  a  most  academic,  and 
at  the  same  time  comprehensive  study,  of  3000  specimens,  examined 
both  grossly  and  microscopically,  in  the  fresh  state  immediately  after 
surgical  removal.  An  attempt  was  made  not  to  color  the  observations 
in  any  way  by  speculations  nor  by  previous  descriptions. 

There  are  two  main  divisions  of  the  types  of  goiter:  the  symmet- 
rical or  thyroid-shaped  and  the  asymmetrical  or  nodular  goiter.  This 
very  general  classification  has  no  special  interest  except  in  the  study 
of  the  gland  as  a  mechanical  system  of  units. 

In  the  symmetrical  group  are  found,  histologically,  any  one  or  a 
combination  of  the  following  conditions:  (a)  a  simple  dilatation,  with 
colloid  of  the  glands,  which  may  be  called  the  "hypertrophic  colloid 
goiter;"  an  increase  in  the  size  of  the  cells  lining  each  acinus,  called 
the  "hypertrophic  parenchymatous  goiter;"  an  increase  in  the  number 
of  cells  in  each  acinus,  in  the  "hypertrophic  colloid  parenchymatous 
goiter;"   or  a  mixture  of  any  or  all  of  these  types. 

In  the  asymmetric  or  nodular  type  of  goiter  there  are  those  that  give 
evidences  of  general  or  systemic  involvement  and  those  that  give  signs 
and  symptoms  due  only  to  the  presence  of  the  growth  in  the  neck. 
The  latter  are  most  commonly  called  "  simple"  and  the  former  "  exoph- 
thalmic." Pathologically  there  are  seen  goiters  with  and  goiters 
without  hypertrophy  or  hyperplasia.  The  majority  of  goiters  in  the 
"simple"  list  do  not  show,  microscopically,  hypertrophy  or  hyper- 
plasia. Conversely,  the  great  majority — and  possibly  all — of  the  speci- 
mens removed  from  patients  wdth  symptoms  of  "exophthalmic"  goiter 
show  positive  evidences  of  such  changes.  These,  in  substance,  are  the 
main  constant  findings  generally  recognized  by  most  of  the  observers. 

Plummer-  after  correlating  the  clinical  findings  in  a  large  number  of 
cases  of  goiter  coming  to  operation,  with  the  pathological  findings  of 
Wilson  and  MacCarty  in  the  same  cases,  divides  goiters  according  to 
their  clinical  and  pathological  relationship  into  four  groups: 
Group     I.  Xon-hyperplastic  atoxic. 
Group    II.  Non-hyperplastic  toxic. 
Group  III.  Hyperplastic  atoxic. 
Group  IV.  Hyperplastic  toxic. 

Xon-hyperplastic  Atoxic  Goiter. — Under  this  heading  may  be 
considered  all  so-called  "simple"  or  "colloid"  goiters  associated  with 
which  there  are  no  systemic  symptoms  that  may  be  attributed  to  the 
enlarged  thyroid  gland.  Grossly,  these  thyroids  are  large,  lobulated, 
hard  growths  which  usually  cause  pressure  against  the  surrounding 
structures.  Upon  section,  a  thick  mucilaginous  substance  or  colloid 
is  seen  in  easily  visible  distended  acini.  Various  degenerations  are  often 
present,  usually,  however,  being  cystic  or  hemorrhagic  changes.  These 
degenerated  areas  are  most  often  found  in  the  center  of  the  gland, 
leaving  an  outside  layer  of  thyroid  tissue  well  supplied  with  blood  from 

>  Surg.,  Gynec.  and  Obst.,  April,  1913,  p.  406. 
2  Am.  Jour.  Med.  Sc,  1913. 


GOITER 


775 


the  adjoining  capsule.  Microscopically,  there  are  seen  large  dilated 
acini  filled  with  eosin-staining  colloid  and  lined  with  a  single  layer  of 
cuboidal  cells.  In  many  instances  these  lining  cells  are  flattened  out 
to  a  marked  degree,  indicating  pressure  from  overdistention. 


Fig.  539. — Dilated  acini  filled  with  colloid 
in  a  case  of  simple  goiter. 


Fig. 


540. — -Degenerated  colloid  goiter  in 
a  case  with  toxic  symptoms. 


NoN-HYPERPL.iSTic  Toxic  GoiTERS. — In  this  group  are  found 
enlarged  thyroid  glands  without  evidences  of  hypertrophy  or  hyper- 
plasia, but  in  which  there  have  been  symptoms  apparently  traceable 
to  the  gland,  which  symptoms  are  not  identical  with  those  found  in 
cases  of  hyperthyroidism.  In  some  instances  this  toxemia  is  due,  in 
all  probability,  to  the  absorption  of  products  from  degenerated  areas 
in  the  gland.    In  other  cases  there  are  found  no  microscopic  processes 


Fig.  541. — A  lymph  follicle  in  thyroid 
tissue. 


Fig.  542. — Diffuse  colloid  adenoma  in  a 
case  of  simple  goiter. 


to  account  for  the  fact  that  the  gland  is  secreting  some  substance  which 
is  not  present  in  the  normal  gland.  There  is  less  definite  clinical  and 
pathological  knowledge  of  this  group  of  cases  than  of  any  of  the  other 
groups. 


770    DISEASES  OF   THE   THYROID  AND  PARATHYROID  GLANDS 

Hyperplastic  Atoxic  Goiters. — In  only  0.8  per  cent,  of  the  cases 
showing  no  symptoms  of  hyperthyroidism  are  found  microscopic  areas 
of  hyperplasia  after  operation.  The  fact  that  this  class  is  so  very  small 
is  the  best  evidence  that  there  is  a  definite  relationship  in  nearly  all 
cases  between  clinical  symptoms  and  pathological  findings,  and  which 
fact  thereby  gave  Plummer  a  basis  for  founding  such  a  classification. 


Fig.  543. — Fetal  and  colloid  adenoma  in 
a  case  of  simple  goiter. 


Fig.  544.- 


-Mixed  adenoma  in  a  case  of 
simple  goiter. 


Hyperplastic  Toxic  Goiters. — It  is  in  this  group  that  cases  of 
"hyperthyroidism"  or  "exophthalmic  goiter"  are  classified.  In  most 
cases  the  typical  findings  can  be  made  out  in  all  portions  of  the  gland, 
while  in  others  it  mav  be  necessarv  to  utilize  serial  sections  of  difi'erent 


Fig.  545. — Hypertrophy  in  a  colloid 
adenoma. 


Fig. 


546. — -Secondary  hyperplasia  in  an 
exophthalmic  goiter. 


portions  of  the  gland  to  demonstrate  h^T^erplasia,  as  very  often  a  small 
piece  removed  for  examination  is  not  representative  of  the  entire 
pathology  of  the  organ  removed.  It  would  seem  from  this  observation 
that  a  very  small,  possibly  microscopic,  area  of  hyperplasia  in  a  gland 
may  be  the  cause  of  constitutional  symptoms. 


GOITER 


111 


There  are  several  types  of  hyperplasia  to  be  found  in  these  goiters. 
The  simplest  type,  hypertrophic  parenchymatous  goiter,  consists  of 
glands  the  lining  cells  of  which  have  increased  in  size,  but  usually  not 
in  numbers.  Colloid  may  be  but  usually  is  not  present  in  the  acini. 
In  the  gross  this  gland  has  the  appearance  of  raw  beef,  is  solid,  symmet- 
rical and  usually  not  large. 


Fig.  547. — Typical  hypertrophy  and 
hyperplasia  in  a  case  of  exophthalmic 
goiter. 


Fig.  548. — Fetal  adenoma  with  marked 
fibrosis  of  interstitial  tissue,  case  with 
mild  symptoms  of  hyperthyroidism. 


When  the  cells  have  markedly  increased  in  number  within  each 
acinus,  due  to  secondary  hyperplasia,  so  as  to  give  the  appearance  of 
a  papilloma-like  growth,  it  is  called  a  hypertrophic  colloid  and  paren- 
chymatous goiter.    These  types  of  hyperplasia  are  usually  found  in 


Fig.  549. — Carcinoma  of  thyroid  gland. 


Fig.  550. — Tertiary  hyperplasia  of  an 
adenoma  with  beginning  malignancy. 


symmetrical  goiters.  Asymmetrical  or  nodular  goiters  owe  their  irregu- 
larity practically  always  to  the  presence  of  one  or  several  adeno- 
mata of  different  shapes  and  sizes,  and  which  are  usually  definitely 
encapsulated  in  fibrous  tissue.     These  adenomata  are   the  result  of 


778    DISEASES  OF  THE  THYROID  AND  PARATHYROID  GLANDS 

local  glandular  hyperplasia,  /.  e.,  instead  of  an  increase  in  size  or  number 
of  cells  in  each  acinus  there  is  a  great  increase  in  the  number  of  acini. 
Grossly,  when  there  is  no  degeneration  present,  the  adenoma  has  a 
solid,  smooth  appearance  in  which  there  can  be  seen  very  little  if  any 
visible  colloid. 

The  acini  are  of  the  fetal  type  in  practically  every  instance,  though 
in  some  cases  a  comparatively  small  number  of  the  fetal  acini  are  found. 
The  adenomata  may  vary  in  diameter  from  1  mm.  to  several  centi- 
meters, and  they  may  undergo  any  type  of  degeneration.  One  occa- 
sionally sees  in  one  goiter  all  of  the  following:  granular,  fatty,  fibrous, 
cystic,  hemorrhagic,  hyaline,  necrotic  and  calcareous  changes.  Such 
goiters  are  very  nodular  and  characteristic  in  appearance.  Cystic 
degeneration  is  the  form  most  commonly  seen.  These  cysts  usually 
contain  cholesterin  crystals  such  as  are  usually  seen  in  cysts  of  long 
duration  in  any  part  of  the  body  when  accompanied  by  hemorrhage. 
In  those  portions  of  the  goiter  surrounding  the  adenomata  may  be 
found  normal  tissue  undergoing  pressure  changes  or  any  of  the  forms 
of  hypertrophy  or  hyperplasia  previously  described. 

Tertiary  hyperplasia  or  carcinoma  is  rather  rarely  encountered  either 
within  adenomata  or  in  the  surrounding  goiter  substance. 

NON-HYPERPLASTIC  GOITER  (SIMPLE  GOITER). 

Symptoms. — The  symptoms  of  simple  goiter  are  mechanical,  that  is, 
they  are  all  secondary  to  pressure  on  the  surrounding  structures. 
These  symptoms  do  not  depend  so  much  upon  the  size  of  the  goiter 
as  upon  the  shape  and  consistency  and  its  location,  especially  in  rela- 
tion to  the  trachea.  The  most  common  symptom  is  dyspnea,  which  is 
usually  due  to  direct  pressure  upon  the  trachea,  causing  the  deviation 
or  compression  of  the  same,  or  less  frequently  it  is  produced  secondarily 
by  pressure  on  the  bloodvessels,  with  consequent  disturbance  of  the 
circulation.  This  occurs  only  from  the  pressure  of  very  large  goiters. 
Very  moderate  or  very  small  goiters  may  produce  marked  deviation 
of  the  trachea,  causing  very  distressing  symptoms  if  a  nodule  happens 
to  become  wedged  in  between  the  trachea  and  esophagus.  Dyspne'a 
may  be  constant  or  paroxysmal  and  is  increased  upon  exertion.  In  the 
beginning  it  is  usually  present  only  on  exertion.  In  substernal  and 
intrathoracic  goiter  there  is  liable  to  be  considerable  deformity  of  the 
trachea  on  account  of  their  situation,  with  rather  constant  respiratory 
symptoms.  When  the  lumen  of  the  trachea  is  greatly  compressed 
there  may  be  present  a  whistling  sound  during  inspiration  and  expira- 
tion, the  so-called  tracheal  stridor.  Occasionally  a  small  goiter,  spheri- 
cal in  character,  involving  the  median  lobe,  may  cause  little  or  no  dis- 
comfort when  the  patient  is  in  the  sitting  or  the  erect  position,  but  as 
soon  as  she  lies  upon  her  back,  the  goiter  causes  pressure  upon  the 
trachea,  causing  more  or  less  marked  dyspnea. 

Occasionally  in  large  bilateral  goiter,  and  frequently  in  the  intra- 
thoracic form,  there  is  an  obstruction  of  the  venous  circulation,  evi- 


NON-HYPBRPLASTIC  GOITER  779 

denced  by  an  enlargement  of  the  anterior  external  jugulars,  and  occa- 
sionally by  cyanosis  of  the  face,  lips  and  tongue  and  by  headache. 
A  secondary  dyspnea  is  usually  present. 

Dysphagia. — Actual  dysphagia  does  occur  but  is  extremely  rare. 
Many  patients,  however,  will  complain  of  some  feeling  of  pressure 
during  deglutition. 

hivohement  of  Nerves. — More  or  less  pressure  on  one  or  both  laryn- 
geal nerves  is  quite  common.  Temporary  hoarseness  is  quite  frequent 
and  is  noticed  on  taking  sKght  colds  or  from  any  excessive  use  of  the 
voice.  Constant  pressure  on  either  nerve  may  produce  a  paralysis  of 
the  nerve,  with  a  consequent  change  of  the  voice.  If  the  pressure  on 
the  nerve  has  been  gradual  the  patient  may  not  have  noticed  the  change 
of  voice  tones.  A  sudden  paralysis  of  one  nerve  will  result  in  an  imme- 
diate hoarseness,  but  this  may  gradually  disappear  by  a  swinging  over 
of  the  healthy  vocal  cord  to  the  paralyzed  cord. 

Matthews^  in  a  careful  examination  of  1000  consecutive  cases, 
found  17  patients  with  a  paretic  affection  of  both  cords,  93  with  an 
involvement  of  the  right  cord  alone  and  162  with  involvement  of  the 
left  vocal  cord.  Thus  the  frequency  of  involvement  of  the  recurrent 
laryngeal  nerves  makes  it  important  to  determine  the  condition  of  the 
nerves  when  a  surgical  operation  is  contemplated.  If  it  is  found  that  one 
vocal  cord  is  paralyzed  the  surgeon  should  use  extreme  care  to  avoid 
any  manipulation  that  might  cause  any  interference  with  the  nerve  on 
the  opposite  side.  The  sA'mpathetic  nerve  is  rarely  affected  in  ordinary 
goiter.  Plummer^  has  observed  both  paralysis  and  irritation  of  the 
sympathetic,  but  states  that  it-  is  not  always  possible  to  determine 
whether  the  disturbances  are  due  to  mechanical  or  functional  causes. 
The  paralysis  affects  chiefly  the  oculopupillary  fibers,  while  the  irrita- 
tion shows  itself  in  the  vasomotor  and  secretory  nerves. 

Pam. — Pain  which  can  be  attributed  to  simple  goiter  is  extremely 
rare;  when  present  it  usually  indicates  some  inflammatory  process. 
Occasionally  in  suddenly  increasing  goiters  due  to  a  hemorrhage  taking 
place  in  the  gland,  pain  will  be  present,  but  disappears  as  soon  as  the 
increased  tension  has  subsided. 

Cough.- — Cough  is  not  an  uncommon  symptom.  When  present  it 
is  due  to  pressure  upon  the  trachea.  The  patient  usually  locates  the 
source  of  the  cough  as  being  in  the  larynx. 

Diagnosis. — The  diagnosis  of  goiter  in  itself  usually  is  not  a  difficult 
matter,  because  of  the  definite  location  of  the  thyroid  gland  and  its 
attachment  to  the  trachea,  causing  it  to  move  upward  during  the  act 
of  swallowing.  The  goiter,  unless  it  be  a  very  large  one,  occupies  the 
normal  position  of  the  thyroid  gland.  This  is  practically  always  the 
case  in  diffuse  goiter,  which  ordinarily  retains  the  shape  of  the  normal 
gland.  Uniform  enlargement  of  the  entire  gland,  however,  is  not  the 
rule.  One  lateral  lobe  and  the  isthmus  are  more  frequently  involved 
than  both  lateral,  the  right  one  being  involved  more  often  than  the 

1  Jour.  Am.  Med.  Assn.,  1910,  pp.  826-828.  2  Ibid.,  1912. 


780     DISEASES  OF   THE   THYROID  AND  PARATHYROID  GLANDS 

left.    ^Yhen  both  lateral  lobes  are  involved  the  right  is  usually  larger 
than  the  left. 


Fig.  551. — Goiter  invoh'inu  lnjtli  lolics  and  larger  on  the  right.     Note  that  this  goiter  is 
a^diffuse  enlargement  of  the  gland  and  that  the  normal  shape  of  the  gland  is  retained. 

Nodular  goiter,  in  contradistinction  to  the  diffuse  form,  is  liable  to 
occupy  a  different  position,  and  more  frequently  makes  pressiu-e  upon 
the  surrounding  structures,  depending  greatly  upon  the  size,  shape 


Fig.  552. — Diffuse  goiter  which  is  well  restrained  behind  neck  muscles. 

and  location  of  the  tumor.     Occasionally  one  meets  with  a  nodular 
goiter  in  which  the  growth  involves  only  the  lower  pole  of  one  lobe, 


NON-HYPERPLASTIC  GOITER 


781 


this  extending  downward  beneath  the  sternum,  so  that  no  enlargement 
of  the  thyroid  is  noticed.  The  position  of  a  goiter  is  determined  by 
inspection,  palpation,  percussion  and  auscultation.    Occasionally  the 


Fig.  553. — Substernal  goiter.  The  left  lobe  is  chiefly  involved  and  lies  behind  the 
manubrium.  Great  care  must  be  exercised  in  dislocating  these  retrosternal  goiters  or 
else  serious  hemorrhage  or  pneumothorax  may  result. 

diffuse  forms  of  goiter,  as  well  as  the  intrathoracic  goiter,  cannot  be 
recognized  by  inspection.  This  applies  particularly  to  the  soft  follic- 
ular and  parenchymatous  type,  especially  when  they  are  not  large  and 


Fig.  554. — Goiter  of  the  Isthmus.     These  goiters  can  be  removed  through  a  very  small 

coUar  incision. 


the  patient  has  well-developed  muscles  of  the  neck.  It  is  in  such 
cases  of  goiter  that  the  functional  symptoms  which  chiefly  attract 
attention  are  so  often  thought  to  be  due  to  a  variety  of  causes  and 


782     DISEASES  OF   THE  THYROID  AND  PARATHYROID  GLANDS 

treated  accordingly.  The  up-and-down  movement  of  the  tumor  (hiring 
deghitition,  which  is  characteristic,  can  usually  be  seen  a  considerable 
distance  from  the  patient.  The  movement  is  due  to  the  close  connec- 
tion between  the  external  capsule  of  the  goiter  and  the  trachea  and 
esophagus.  In  cases  in  which  it  is  difficult  to  palpate  the  goiter,  the 
tumor  may  be  rendered  more  palpable  and  ^'isible  by  ha^'ing  the  patient 
cough.  In  retrosternal  goiter  the  tumor  can  often  be  seen  and  felt 
only  when  the  patient  coughs.  Most  goiters  can  be  moved  rather 
freely  in  the  surrounding  tissue,  the  mobility  being  much  greater  in 
the  lateral  directions  than  up  and  down. 

Percussion  and  auscultation  are  frequently  of  value  in  the  diagnosis 
of  intrathoracic  goiter.  Quite  markei  dulness  with  a  rounded  lower 
border  and  beginning  at  the  upper  aperture  of  the  thorax,  is  usually 
present.  Percussion  and  auscultation  of  the  larynx  and  trachea  yield 
dulness  on  the  side  of  the  goiter  and  diminished  tracheal  breathing, 
which  are  suggested  by  Kocher  as  being  important  diagnostic  signs 
in  struma  intrathoracica. 

The  differential  diagnosis  between  goiter  and  a  branchial  cyst  is 
usually  not  difficult,  the  latter  being  more  regular  in  outline,  ap])earing 
as  a  smooth,  soft,  spherical  mass  without  symptoms  and  growing  very 
slowly.  Fluctuation  is  usually  distinct  and  the  thyroid  gland  can 
usually  be  palpated  separately  from  the  cyst. 

Lymphosarcomata  may  develop  in  any  location  of  the  neck.  When 
located  anterior  to  the  sternomastoid  muscles  they  may  appear  in  the 
region  of  either  lateral  lobe  of  the  thyroid.  The  mass,  however,  is 
usually  more  definitely  lobulated,  and  frequently  the  involved  indi- 
vidual glands  can  be  palpated.  The  mass  is  not  as  movable  as  a  goiter 
and  does  not  move  up  and  down  with  the  larynx  during  deglutition. 

Enlarged  lymj)h  glands  due  to  leukemia  or  pseudoleukemia  are  not 
apt  to  be  mistaken  for  goiter  for  the  same  reason  as  given  in  connection 
with  lymphosarcoma  and  because  they  usually  appear  high  in  the  neck 
and  not  in  the  region  of  the  thyroid. 

Treatment. — Goiter  is  a  disease  which  has  a  tendency  to  progress 
indefinitely  unless  it  is  controlled  by  medical  or  surgical  treatment  or 
by  change  of  climate  or  by  diet.  In  a  large  percentage  of  cases,  espec- 
ially in  children  and  young  adults,  the  treatment  belongs  to  the 
internist.  The  early  simple  hypertrophy  will  usually  subside  by  the 
administration  of  some  form  of  iodin,  with  the  judicious  use  of  thyroid 
extract.  Space  forbids  the  discussion  of  internal  treatment  further 
than  to  say  that  appropriate  internal  treatment  must  be  based  upon 
an  accurate  investigation  of  the  goiter  and  the  patient.  In  the  past 
much  harm  has  been  done  by  the  indiscriminate  use  of  iodin  prepara- 
tions and  thyroid  extract.  It  is  also  important  to  investigate  various 
sources  of  infections,  such  as  decayed  teeth,  infections  of  the  various 
sinuses  and  especially  infected  tonsils,  and  if  any  of  these  are  present 
they  should  be  taken  care  of  as  the  first  step  in  the  treatment.  During 
the  past  two  years  the  author  has  found  that  in  children  and  in  young 
adults  who  have  come  under  our  care  with  goiters  the  vast  majority 


NON-HYPERPLASTIC  GOITER  783 

also  had  infected  tonsils.  Such  tonsils  should  be  removed,  and  then 
if  the  case  is  one  in  which  it  seems  likely  that  relief  can  be  obtained 
without  further  surgical  interference,  appropriate  medical  treatment 
should  be  instituted. 

Indications  for  Surgical  Treatment. — In  the  vast  majority  of  cases 
of  simple  goiter  the  indications  for  surgical  treatment  can  be  deter- 
mined primarily  instead  of  treating  them  with  internal  medicines  first 
and  referring  them  to  the  surgeon  only  if  the  internal  treatment  fails. 

1.  All  goiters  producing  pronounced  pressure  symptoms  should  be 
treated  by  operation. 

2.  Nodular  goiters,  especially  those  in  the  process  of  secondary 
degeneration,  seldom  are  amenable  to  medical  treatment.  These 
degenerative  processes  can  usually  be  determined  by  the  changes  in 
their  consistency.  Thus  the  nodular  colloid,  the  fibrous,  calcareous, 
and  cystic  nodular  goitres  are  surgical. 

3.  Operation  is  indicated  in  all  cases  of  simple  goiter  showing  any 
toxic  symptoms,  and  in  many  cases  because  its  uninterrupted  course 
involves  considerable  risk  of  future  development  of  toxemia  or  malig- 
nancy. 

4.  Large,  diffuse  colloid  goiters  should  be  removed  and  the  smaller 
diffuse  colloidal  enlargements  may  be  considered  surgical  after  they 
have  resisted  a  thorough  iodin  medication. 

5.  The  removal  of  adenomata  is  desirable,  especially  as  a  prophy- 
lactic measure  against  toxemia,  as  they  seldom  if  ever  disappear 
spontaneously,  and,  according  to  Plummer,  at  least  25  per  cent,  of 
adenomata  ultimately  develop  well-marked  signs  of  pressure  or 
thyrotoxicosis. 

6.  In  a  small  percentage  of  cases  goiters  may  be  removed  for  cosmetic 
reasons  only. 

Operative  Measures. — There  are  various  operative  measures  such  as: 

1.  Excision  (Kocher). 

2.  Enucleation  (Porta  and  Socin). 

3.  Resection  (Mikulicz). 

4.  The  combined  methods. 

5.  Exenteration  (Kocher). 

6.  Ligation  of  arteries  (Nolfier). 

Excision. — In  probably  30  per  cent,  of  cases  of  simple  goiter  the 
growth  is  confined  to  one  lobe  in  the  form  of  multiple  adenomata  or  a 
single  encapsulated  adenoma  or  cyst.  Iji  such  cases  an  excision  of  the 
involved  lobe,  together  with  the  isthmus,  leaving  only  the  posterior 
capsule  of  the  gland  to  protect  the  parathyroid  and  recurrent  laryngeal 
nerve,  is  the  operation  of  choice.  When  besides  the  marked  enlarge- 
ment of  one  side  there  is  also  a  similar  involvement  of  the  opposite 
side,  it  is  well  to  make  a  complete  excision  of  the  larger  lobe  and  a 
resection  of  the  smaller  side,  together  with  the  isthmus. 

Enucleation. — In  some  cases  of  single  or  multiple  encapsulated 
adenomata  they  may  readily  be  enucleated,  thus  preserving  the 
remainder  of  the  thyroid.     This  is  readily  accomplished  by  simply 


784     DISEASES  OF   THE   THYROID  AND  PARATHYROID  GLANDS 

elevating  the  lobe  of  the  gland,  making  an  incision  through  the  capsule 
at  the  point  where  the  tumor  presents  and  then  shelling  out  the  tumor 
from  the  gland.  The  thyroid  should  be  kept  elevated  and  under  some 
tension  to  control  the  bleeding.  A  fine  catgut  suture  is  passed  through 
and  through  the  thyroid,  obliterating  the  space  from  which  the  tumor 
has  been  removed,  and  at  the  same  time  controlling  the  hemorrhage. 

Resection. — In  large  colloid  goiters  it  is  often  well  to  make  a  double 
resection,  removing  the  greater  portion  of  both  lobes.  After  the  gland 
has  been  exposed  and  both  lobes  dislocated  a  large  wedge-shaped 
portion  of  the  gland  on  either  side  is  cut  away  and  the  two  surfaces 
of  each  lobe  are  brought  together  by  a  running  catgut  suture,  which 
also  controls  the  hemorrhage.  The  isthmus  should  either  be  divided 
or  removed  to  permit  the  two  edges  of  each  lobe  to  come  together  more 
readily.  When  the  operation  is  completed  the  remaining  portion 
resembles  somewhat  a  normal  thyroid  lobe. 

Exenteration. — Exenteration,  as  suggested  by  Kocher,  is  a  method  of 
reducing  the  size  of  the  gland,  in  some  cases  of  large  colloid  goiter,  by 
exposing  the  gland,  opening  its  capsule  and  curetting  away  all  of  the 
soft  colloid  material,  then  suturing  the  capsule. 

Ligation  of  Arteries. — Ligation  of  arteries  is  seldom  indicated  in 
simple  goiter.  It  is  sometimes  of  value  in  small  vascular  goiters,  but 
it  is  most  often  employed  as  a  preliminary  operation  in  Grave's  disease. 
It  may,  however,  be  used  to  advantage  in  cases  of  simple  goiter  in  com- 
bination with  excision,  in  cases  showing  mild  toxic  symptoms  where 
the  enlargement  is  confined  to  one  lobe  or  the  other  lobe  is  only  slightly 
involved.  In  such  cases  it  is  advisable  to  make  an  excision  of  the  large 
lobe  and  isthmus  and  to  ligate  the  superior  vessels  on  the  opposite  side. 
By  this  plan  the  patient  is  more  likely  to  obtain  complete  relief  than 
by  the  simple  excision  of  the  one  lobe. 

NON-HYPERPLASTIC  TOXIC  GOITER. 

This  group  includes  a  class  of  patients  suffering  from  goiter  which 
have  existed  for  a  considerable  time,  often  many  years,  without  pro- 
ducing any  recognizable  symptoms,  when  gradually  degenerative 
symptoms  develop,  especially  those  of  the  cardiovascular  system.  These 
symptoms  have  been  attributed  to  various  causes,  all  of  which,  so  far, 
are  simply  speculations.  Kocher  has  drawn  attention  to  the  fact  that 
occasionally  during  the  treatment  of  simple  goiter  with  iodin  severe 
symptoms  of  intoxication  develop.  The  author  has  encountered  this 
same  condition  several  times.  It  is  probable  that  the  sjinptoms  are 
due  to  the  absorption  of  some  toxin,  but  until  we  know  what  the  toxin 
is  we  must  still  remain  in  the  realm  of  speculation.  For  all  practical 
purposes  it  is  sufficient  to  know  that  the  toxin  is  developed  in  the 
thyroid  gland  and  that  many  simple  goiters  may  and  will  develop  into 
toxic  goiters.  Plummer  has  showTi  there  is  sufficient  evidence  to  prove 
that  these  patients  comprise  a  group  distinct  from  the  exophthalmic 
goiters,  and  that  they  rarely  develop  into  cases  of  Graves's  disease. 


NON- HYPERPLASTIC  TOXIC  GOITER  785 

This  group  of  cases  has  a  more  or  less  constant  train  of  symptoms, 
vnih  varying  degrees  of  intensity.  The  symptoms  come  on  very  grad- 
ually, the  first  and  most  constant  of  which  is  tachycardia.  Plummer^ 
found,  in  a  large  series  of  cases,  that  patients  in  this  group  gave  a  goiter 
history  beginning  at  twenty-two  years  of  age,  and  that  the  first  symp- 
toms of  intoxication  appeared  at  36.5  years  of  age.  Corresponding 
ages  for  patients  with  exophthalmic  goiter  was  32.9  years,  that  is,  the 
s\Tnptoms  appeared  shortly  after  the  goiter  was  discovered. 

In  the  non-hj^erplastic  group  the  symptomatology  varies  greatly 
from  very  mild  to  extreme  condition.  Many  times  the  patient  consults 
the  physician  about  a  goiter  because  of  its  size  and  is  not  conscious  of 
the  gland  having  produced  any  intoxication,  but  early  cardiovascular 
changes  can  be  demonstrated.  Myocardial  changes  predominate  and 
in  long-standing  cases  may  be  more  marked  than  in  true  exophthalmic 
goiters.  In  the  majority  of  cases,  besides  tachycardia,  nervousness  and 
tremor  are  present,  but  develop  slowly  and  are  less  marked  than  in  the 
hjT^erplastic  group. 

The  course  of  the  disease  is  one  of  a  mild  toxemia  persisting  without 
marked  exacerbations,  such  as  occur  in  true  exophthalmic  goiter;  thus 
the  continued  poisoning  has  a  tendency  to  lead  to  irreparable  damage 
to  the  heart  and  to  the  kidneys.  The  thyrotoxicosis  varies  greatly  in 
degree  in  different  cases.  Oftentimes  it  is  so  mild  that,  except  for 
tachycardia,  slight  muscular  weakness  and  mild  nervous  symptoms, 
these  patients  sufi^er  very  little  inconvenience  for  a  long  time.  Vaso- 
motor signs  frequently  develop,  but  usually  in  a  lesser  degree  than  in 
Graves's  disease.  Occasionally,  however,  the  symptoms  are  so  marked 
that  it  is  difficult  to  differentiate  between  this  form  of  toxic  goiter  and 
a  true  exophthalmic  case. 

The  pathological  findings  in  this  group  are  not  constant  other  than 
that  h}TDerplasia  of  the  gland  is  not  present.  In  the  majority  of  cases 
the  pathological  picture  resembles  that  of  simple  goiter,  and  the 
assumption  is  that  the  toxemia  is  frequently  due  to  the  absorption  of 
products  from  degenerated  areas  in  the  gland. 

Treatment. — The  indication  for  treatment  in  this  group  of  cases  is 
very  definite.  The  condition  being  due  to  a  toxic  process  which 
gradually  progresses,  the  rational  treatment  consists  in  removal  of  the 
source  of  the  toxemia,  the  thyroid  gland.  The  operative  procedure 
in  mild  cases  is  similar  to  that  in  cases  of  simple  non-toxic  goiter, 
and  in  the  later  cases  to  that  of  true  Graves's  disease,  which  is  dis- 
cussed in  detail  on  page  793. 

The  results  from  surgical  treatment  are  very  satisfactory  if  the 
operation  is  performed  early  before  irreparable  damage  has  been  done 
to  the  heart  and  kidneys.  Even  in  the  late  cases,  although  the  opera- 
tion is  accompanied  by  some  risk,  siu-gical  interference  is  indicated  to 
cut  off  the  source  of  the  intoxication,  thus  giving  the  patient  a  chance 
for  at  least  partial  recovery. 

1  Jour.  Am.  Med.  Agsn,,  1912. 
VOL.  I — 50 


786     DISEASES  OF   THE   THYROID  AND  PARATHYROID  GLANDS 

Too  much  stress  cannot  be  placed  upon  the  early  diagnosis  and  the 
importance  of  an  early  operation  in  all  cases  of  hyperthyroidism  in 
adults  with  this  gradual  progressive  type.  Early  operation  is  not 
only  important  because  of  the  better  chances  of  a  complete  cure,  but 
it  eliminates  practically  all  the  risk  of  the  operation,  as  the  dangers 
depend  largely  upon  the  amount  of  harm  done  before  the  operation. 

Careful  judgment  is  required  in  these  cases  in  determining  the 
amount  of  thyroid  tissue  to  be  removed,  the  object  being  to  preserve 
only  just  enough  to  prevent  supervening  hypothyroidism.  In  the 
late  cases,  with  marked  cardiac  and  renal  changes,  great  care  is  required 
in  the  entire  surgical  management.  This  is  taken  up  in  detail  later 
under  the  treatment  of  cases  in  Group  IV. 

It  is  well  to  bear  in  mind  that  in  girls  at  about  the  time  of  puberty, 
or  a  little  later,  many  goiters  cause  symptoms  of  a  toxic  nature.  There 
may  be  present  tachycardia,  tremor,  muscular  weakness,  nervous 
excitability  and  other  minor  symptoms.  There  may  also  be  present 
even  a  slight  degree  of  exophthalmos.  Many  of  the  patients  will  make 
a  good  recovery  under  proper  medical  management.  In  brief,  the 
treatment  indicated  is  removal  of  any  focus  of  infection,  such  as  infected 
tonsils,  which  is  often  found  in  these  cases,  then  the  institution  of 
complete  rest,  physical,  mental  and  emotional;  a  diet  composed  largely 
of  milk,  cooked  vegetables  and  fruits:  favorable  hygienic  surroundings 
and  the  avoidance  of  all  condition  which  might  cause  nervous  excite- 
ment. 

HYPERPLASTIC  ATOXIC  GOITERS. 

The  hyperplastic  atoxic  th^Toids  are  so  extremely  rare  that  it  is  not 
necessary  to  consider  them  clinically.  In  a  large  series  of  cases, 
Plummer^  found,  that  of  the  h^-perplastic  goiters  coming  to  operation 
only  0.8  per  cent,  did  not  give  the  clinical  symptoms  of  exophthalmic 
goiter.  Since  Wilson  called  attention  to  the  relationship  between 
h}T)erplasia  of  the  thyroid  and  exophthalmic  goiter  we  have  made  a 
routine  microscopic  examination  of  all  the  goiters  removed,  and  in 
every  case  evidence  of  hyperplasia  has  been  found  in  some  portion  of 
the  gland. 

HYPERPLASTIC  TOXIC  GOITER  (EXOPHTHALMIC  GOITER). 

H}T)erplastic  toxic  goiter,  exophthalmic  goiter  or  Graves's  disease 
is  characterized  by  a  rather  definite  train  of  signs  and  symptoms,  the 
most  prominent  of  which  are  tachycardia,  exophthalmos,  muscular 
tremor  and  weakness,  vasomotor  affection,  disorders  of  metabolism, 
with  many  other  manifestations  of  disturbances  of  the  nervous  func- 
tions. There  seems  to  be  a  definite  relation  between  the  clinical  and 
pathological  findings  in  this  group,  as  the  disease  is  practically  always 
associated  with  hj-perplasia  of  the  parenchyma  of  the  thyroid.  This 
disease  was  described  by  Parry^  over  a  century  ago,  and  again  in  1835 

1  Jour.  Am.  Med.  Assn.,  1912. 

2  Quoted  by  Ochsner  and  Thompson,  Thyroid  and  Parathyroid  Glands,  1910. 


HYPERPLASTIC  TOXIC  GOITER 


787 


Graves^  described  all  the  clinical  symptoms  so  clearly  that  it  became 
known  as  Graves's  disease.  While  very  little  is  known  of  the  etiology 
of  exophthalmic  goiter,  the  theory  advanced  by  Moebius^  in  1886  is 
still  quite  generally  accepted,  that  is,  that  in  this  disease  there  is  an 
absorption  of  some  toxic  substance  secreted  by  a  diseased  thyroid 
gland  which  enters  the  general  circulation  through  the  hmphatic 
system.  There  is,  however,  no  definite  knowledge  as  to  what  prompts 
the  thyroid  to  this  hyperactivity  or  as  to  the  nature  of  the  toxin  con- 
cerned or  as  to  its  mode  of  action  in  producing  the  various  constitu- 
tional sjTnptoms.  In  our  own  cases  at  the  Augustana  Hospital,  in  the 
majority  of  instances,  it  has  been  possible  to  demonstrate  even  in  the 
gross  specimen  some  portion  that  showed  hypertrophy,  and,  histo- 
logicalh',  practically  every  specimen  showed  typical  tissue  in  some 


Fig.  555. — ^Very  small  toxic  goiter,  exophthalmos.  Note  the  excellent  delineation  of 
the  neck  muscles  and  the  tension  with  which  they  are  held  indicating  the  degree  of 
nervous  tension  the  patient  lives  under. 

portion.  The  clinical  s\Tnptoms  do  not  necessarily  correspond  with 
the  extent  of  goiter,  as  thyroids  containing  only  a  small  portion  of 
diseased  tissue  may  produce  the  most  severe  symptoms.  When  one 
bears  in  mind  the  fact  that  any  one  of  a  number  of  active  drugs,  with 
which  everyone  is  familiar,  may  produce  violent  symptoms  when 
introduced  into  the  circulation,  it  is  possible  to  suppose  that  the  toxin 
from  even  a  small  portion  of  a  diseased  thjToid  may  produce  the  various 
symptoms  of  this  disease.  It  is  not  uncommon  to  have  a  marked  differ- 
ence in  the  size  of  the  thyroid  from  time  to  time,  also  in  the  same 
manner  the  severity  of  symptoms  varies  greatly. 

There  seems  to  be  a  discharge  into  the  circulation  of  a  considerable 

1  System  of  Clinical  Medicine,  DubHn,  1843 

^  Schmidt's  Jahrb.  d.  in.  und  aus.  gesamt.  Med.,  1886. 


788     DISEASES  OF   THE   THYROID  AND   PARATHYROID  GLANDS 

quantity  of  the  poison  at  intervals.  These  exacerbations  may  occur 
without  any  apparent  cause,  or,  on  the  other  hand,  may  follow  sudden 
mental  or  physical  influences. 

It  is  not  uncommon  for  sorrow  over  the  death  of  some  member  of  the 
family,  excitement  over  a  fire,  sudden  fright,  etc.,  to  give  rise  to  very 
severe  and  sometimes  even  a  fatal  exacerbation  of  this  disease. 

Plummer^  in  describing  the  course  of  the  disease  represents  it  by  a 
curve,  the  greatest  height  of  the  intoxication  is  found  to  be  reached 
during  the  latter  half  of  the  first  year,  and  then  rapidly  drops  to  the 
twelfth  month.  In  many  instances  it  reaches  the  normal  base  line 
during  the  next  six  months,  more  often  it  fluctuates  with  periods  of 
exacerbation  for  the  next  two  to  four  years.  Secondary  symptoms  and 
exophthalmos  may  remain,  but  the  active  course  rarely  continues  over 
four  years  without  distinct  intermissions.  The  ascent  may  be  gradual, 
sudden  or  irregularly  marked  by  many  secondary  curves. 

Etiology. — Exophthalmic  goiter  is  far  more  common  among  women 
than  men,  and  almost  always  shows  itself  first  during  early  adult  life. 
Balfour^  in  an  analysis  of  2928  patients  with  exophthalmic  goiter 
found  "that  85  per  cent,  were  females  and  15  per  cent,  were  males. 
About  10  per  cent,  were  under  twenty  years  of  age.  The  age  of  onset 
was  usually  from  twenty-five  to  thirty-five  years;  the  average  age  at 
which  symptoms  were  noticed  by  the  patient  was  thirty-two  years. 
The  youngest  individual  was  a  girl,  aged  four  years,  and  there  were 
five  cases  under  ten  years  of  age,  all  being  girls." 

There  seems  to  be  no  one  etiological  factor  which  may  be  attributed 
as  a  cause  in  any  considerable  number  of  cases.  In  connection  with  the 
infection  theory  the  writer  has  noticed  that  in  a  considerable  number 
of  cases  of  Graves's  disease  there  is  present  more  or  less  infection  in  the 
mouth,  teeth,  nose  and  especially  in  the  tonsils. 

A  great  many  patients  attribute  their  first  symptoms  to  some 
psychic  disturbance,  usually  a  shock  to  the  nervous  system,  or  excessive 
mental  or  physical  strain.  Moebius's  theory  that  the  disease  is  due  to 
excessive  secret  i  ry  activity  of  the  thyroid  gland  is  still  accepted  by 
many  observers. 

Kocher  has  shown  experimentally  in  animals  that  Graves's  disease 
could  be  produced  by  the  injection  of  thyroid  extract,  thyroid  sub- 
stance of  iodothyroidin,  substantiating  the  theory  that  the  disease  is  a 
hyperthyroidism.  The  fact  that  iodin  therapy  regularly  increases  the 
severity  or  the  symptoms  and  that  excessive  iodin  treatment  in  simple 
goiter  frequently  is  responsible  for  the  development  of  exophthalmic 
goiter,  would  also  bear  out  the  correctness  of  this  theory. 

Crile^  believes  that  exophthalmic  goiter  is  a  "  disease  of  the  motor 
mechanism  that  causes  physical  action  and  expresses  the  emotion;  its 
origin  is  in  phylogeny  and  its  excitation  is  through  some  stimulat- 
ing emotion,  intensely  or  repeatedly  given,  or  some  lowering  of  the 

^  Keen's  Surgery,  vol.  vi. 

-  Mayo  Clinic,  1914,  vol.  vi. 

^  Phylogenetic  Association  in  Relation  to  Certain  Medical  Problems. 


HYPERPLASTIC  TOXIC  GOITER  789 

threshold  of  the  nerve  receptory,  thus   establishing   a   pathological 
interaction  between  brain  and  thyroid." 

Symptoms.  —  Circulatory  Disturbances.  —  1.  Tachycardia.  — 
Tachycardia  is  one  of  the  earliest  and  most  constant  signs  of  exoph- 
thalmic goiter.  This  condition  usually  exists  for  a  considerable  time, 
unknown  to  the  patient,  and  when  discovered,  is  usually  considered 
"palpitation"  and  not  thought  to  be  constant.  While  the  rapidity  of 
the  pulse  varies  greatly  from  time  to  time,  according  to  the  degree  of 
toxemia,  and  with  physical  activity  and  mental  strain,  there  is  always 
present  some  degree  of  tachycardia.  Early  in  the  disease  the  pulse 
ranges  from  100  to  120  beats  per  minute.  In  many  cases  of  Graves's 
disease  the  thyroid  is  not  greatly  enlarged — in  fact,  its  size  is  not 
noticeable.  In  such  cases,  in  the  absence  of  exophthalmos  and  the 
prominence  of  the  tachycardia,  the  true  condition  is  frequently  over- 
looked and  the  case  erroneously  diagnosed  as  one  of  functional  heart 
disorder.  After  the  disease  is  well  established  the  pulse-rate  varies 
from  130  to  160  beats  per  minute,  and  is  usually  accompanied  by 
visible  pulsation  of  the  vein  of  the  neck.  Continued  hyperactivity  of 
the  heart  eventually  results  in  permanent  changes  in  the  cardiovas- 
cular system.  Tachycardia  is  always  associated  with  excitability,  and 
often  irregularity  and  palpitation. 

2.  Murmurs  of  the  Thyroid. — Vascular  arterial  murmurs  of  a  swirling 
character  are  often  obtained  by  auscultation  directly  over  the  enlarged 
gland.  Putnam^  states:  When  present  it  is  probably  pathognomonic, 
but  sometimes  it  may  be  heard  only  over  limited  areas.  This  murmur 
should  be  distinguished  from  the  "hum"  due  to  compression  of  the 
cervical  veins.  In  exophthalmic  goiter  the  presence  or  absence  of  a 
definite  thrill  over  the  superior  thyroid  vessels  is  one  of  the  most 
important  physical  signs  upon  which  a  diagnosis  may  be  based.  A 
definite  thrill  is  very  often  met  with  in  hyperplastic  or  exophthalmic 
goiter,  but  is  rarely,  if  ever,  present  in  non-hyperplastic  goiter. 

Pulsation  of  the  gland  itself  frequently  is  visible  and  may  be  accom- 
panied by  a  palpable  expansion  and  bruit.  Many  patients  are  con- 
scious of  a  constant  throbbing  sensation  in  the  region  of  the  thyroid — 
in  fact,  they  often  complain  of  this  as  their  most  annoying  symptom. 

3.  Cardiac  Signs. — ^The  heart  sounds  are  accentuated,  due  to  the 
excited  and  accelerated  action  of  the  heart.  Blood-pressure  may  be 
a  few  millimeters  above  normal,  but  in  general  it  is  low.  Sooner  or 
later  in  exophthalmic  goiter  there  is  evidence  of  damaged  heart  muscle. 
Secondary  dilatation  is  frequent  and  is  often  accompanied  by  loud 
systolic  murmurs.  The  palpitation,  which  is  usually  marked,  may  cause 
the  patient  great  anxiety.  This  palpitation  may  be  continuous  and 
persistent,  or  it  may  be  intermittent,  appearing  without  any  apparent 
cause,  or  may  be  precipitated  by  any  psychic  influence. 

General  evidences  of  cardiac  insufficiency  may  be  present,  such  as 
dyspnea  and  anasarca.    The  degree  of  cardiac  involvement  has  much 

^  Sajous's  Analytic  Cyclopedia  of  Practical  Medicine,  vol.  v. 


790     DISEASES  OF   THE   THYROID  AND  PARATHYROID   GLANDS 

to  do  with  the  final  outcome  of  these  cases,  the  determination  of  which 
has  more  bearing  upon  the  prognosis  than  any  other  single  symptom. 
Nervous  Phenomena. — 1.  Nervous  Excitability. — In  the  majority 
of  cases  cerebral  excitement  in  some  form  is  usually  referred  to  as 
nervousness.  The  degree  of  excitement  varies  greatly,  is  characterized 
by  a  mental  restlessness;  in  many  patients  their  actions  resemble  very 
much  those  of  a  person  under  the  influence  of  a  stimulating  intoxicant. 
Besides  the  mental  unrest,  there  is  often  present  a  motor  activity  pro- 
ducing choreiform  movements.  As  pointed  out  by  Tinker,  these 
patients  often  complain  of  a  symptom  which  could  readily  be  mistaken 
for  typical  globus  hystericus,  and  which  has  often  caused  various 
observers  to  make  a  diagnosis  of  hysteria  in  patients  suffering  from 
exophthalmic  goiter.  In  severe  acute  hyperthyroidism  the  cerebral 
manifestations  may  resemble  those  of  a  patient  sufi'ering  from  delirium 
tremens.  In  these  cases  the  intoxication  is  usually  severe  enough  to 
result  in  death. 

2.  Mental  Irritability. — Mental  irritability  is  one  of  the  most  con- 
stant and  early  symptoms  of  exophthalmic  goiter,  and  is  but  a  variation 
of  the  cerebral  excitability.  The  patients  become  annoyed  over  trivial 
things,  which  formerly  would  not  have  been  noticed  by  them.  They 
frequently  have  a  dread  of  being  in  the  presence  of  other  persons: 
even  members  of  their  own  families  seem  to  annoy  them.  Mental 
irritability  often  appears  early  in  the  history  and  is  frequently  an 
important  indication  of  the  degree  of  intoxication. 

3.  Mental  Depression. — Late  in  the  disease  a  certain  proportion  of 
these  cases  become  mentally  depressed,  presenting  a  picture  of  melan- 
cholia. This  is  one  of  the  most  definite  evidences  of  the  existence  of 
a  marked  toxemia,  and  often  is  of  serious  import. 

4.  Tremor. — Tremor  is  almost  invariably  present  and  occurs  early 
in  the  disease.  It  is  fine  and  rapid,  eight  to  ten  oscillations  per  second, 
and  appears  first  in  the  hands,  then  later  in  the  head  and  other  portions 
of  the  body.  When  associated  with  marked  muscular  weakness  the 
tremor  may  appear  as  being  coarse  instead  of  the  fine  tremor  as 
described  above.  The  similarity  between  the  tremor  of  chronic  alco- 
holism and  that  of  exophthalmic  goiter  further  supports  the  theory 
of  Moebius,  that  the  disease  is  due  to  a  condition  of  poisoning  through 
toxic  substances  circulating  in  the  blood  and  affecting  the  tissues 
directly.  This  symptom  is  most  easily  elicited  by  having  the  patient 
extend  the  arm  to  a  right  angle  with  the  body,  having  the  fingers 
extended  and  separated.  In  many  patients  tremor  is  an  early  symp- 
tom, and  it  may  be  the  tremor  that  first  causes  them  to  consult  the 
physician.  It  is  important  to  always  bear  in  mind  the  relation  between 
this  symptom  and  exophthalmic  goiter.  The  tremor  remains  constant 
after  it  has  made  its  appearance,  but  varies  greatly  in  its  severity. 
Occasionally  in  patients  who  have  suffered  from  the  disease  for  a  con- 
siderable time;  there  are  present  mild  contractions  of  the  muscles 
resembling  those  of  incipient  chorea.  These  contractions  affect  the 
head  especially,  but  sometimes  also  the  upper  extremities. 


HYPERPLASTIC  TOXIC  GOITER  791 

5.  Muscular  Weakness. — Muscular  weakness  may  be  looked  upon 
as  one  of  the  cardinal  symptoms  of  exophthalmic  goiter.  It  is  always 
present,  but  in  varying  degrees,  being  exceedingly  marked  in  some 
cases.  At  the  history-taking  the  patients  usually  volunteer  the  informa- 
tion that  they  "tire  easily."  Associated  with  the  muscular  weakness 
there  is  usually  a  loss  of  weight;  this,  however,  depends  upon  the 
degree  of  intoxication.  It  may  show  itself  simply  by  the  fact  that  the 
patient  becomes  fatigued  more  easily  than  normal,  or  it  may  be  so 
severe  that  the  patient  suddenly  loses  control  of  certain  muscles  and 
may  drop  things  suddenly.  This  weakness  is  usually  most  marked  in 
the  lower  extremities  and  is  often  most  marked  in  the  hamstring 
muscles.  Many  patients  first  notice  this  condition  from  difficulty  in 
going  down  stairs,  and  also  notice  in  changing  from  the  standing 
to  sitting  position  that  unless  they  steady  themselves  with  their  arms 
they  will  drop  into  the  seat  suddenly  instead  of  gradually,  as  they  had 
expected  to  do.  This  weakness  seems  to  be  due  to  a  condition  of  the 
muscle  tissue  itself,  caused  by  the  poisonous  thyroid  secretion  circu- 
lating in  the  blood.  This  same  condition  affecting  the  muscles  of  the 
orbit  and  of  the  eyelid  probably  have  much  to  do  with  producing  the 
symptom  of  exophthalmos  and  many  other  ocular  symptoms. 

Ocular  Signs. — 1.  Exophthalmos. — Exophthalmos,  even  though  it 
is  the  sign  which  gave  the  disease  its  name,  is  often  lacking.  This  sign 
is  usually  present  in  advanced  cases,  although  it  almost  always  is  pre- 
ceded by  a  number  of  symptoms.  It  is  nearly  always  present  in  acute- 
cases,  and  is  especially  marked  when  the  symptoms  are  brought  on  by 
some  intense  emotional  excitement. 

Retraction  of  the  eyelid  may  be  present  without  exophthalmos,  the 
staring  giving  a  false  impression  of  protrusion  of  the  eyeball.  The 
degree  of  protrusion  may  vary  from  time  to  time  with  the  other  symp- 
toms, sometimes  being  so  great  that  the  eye  is  nearly  dislocated  from 
the  socket.  It  is  likely  that  the  protrusion  of  the  eye  is  due  to  a  weak- 
ened and  relaxed  condition  of  the  muscles  which  normally  keep  the 
eyeball  in  place,  together  with  an  engorgement  of  the  veins  in  the  orbit. 
Early  in  the  disease  the  protrusion  may  appear  suddenly  and  then  sub- 
side just  as  rapidly.  This  fact  strengthens  the  theory  that  a  congestion 
or  engorgement  of  the  vessels  in  the  orbit  aid  in  pushing  the  eyeball 
forward.  Later  on  the  eye  becomes  fixed,  the  protrusion  remaining 
constant,  with  only  slight  variations  in  degree.  Exophthalmos  is  often 
greater  on  one  side  than  the  other,  the  right  eye  usually  being  the  more 
prominent.  The  fact  that  the  right  lobe  of  the  thyroid  is  usually 
involved  to  a  greater  extent  than  the  left  in  exophthalmic  goiter, 
would  suggest  that  the  two  phenomena  are  in  some  way  related.  It 
occasionally  happens  that  the  larger  lobe  of  the  thyroid  and  the  more 
protruding  eye  are  on  opposite  sides. 

Minor  Eye  Signs. — 1.  Von  Graefe's  Sign.^ln  directing  the  eye 
downward  the  lower  margin  of  the  upper  eyelid  does  not  follow  the 
line  of  vision  as  normally  but  lags  behind  and  follows  in  an  irregular 
spastic  manner. 


792    DISEASES  OF   THE  THYROID  AND  PARATHYROID  GLANDS 

2.  Stellwag's  Sign. — The  eyes  have  a  pecuhar  staring  appearance 
when  fixed  on  an  object  and  often  have  a  pecuhar  shmy  look.  Infre- 
quent and  incomplete  winking  is  also  noticeable. 

3.  Dalrym-ph's  Sign. — A  widening  of  the  palpebral  fissure. 

4.  Moehius's  Sign. — An  insufficiency  of  convergence  and  lack  of 
accommodation  at  near-point. 

These  signs  all  occur  with  varying  degrees  of  frequency,  von  Graefe's 
and  Stellwag's  being  most  constant.  They  are  probably  all  due  to  the 
weakening  of  the  eye  muscles,  due  to  the  poisoning  caused  by  the 
hyperthyroidism. 

Vasomotor  Disturbaxces. — 1.  Sweating. — The  most  common  vaso- 
motor sign  is  sweating,  which  is  noticed  early  in  the  disease,  often  is 
very  excessive  and  involves  principally  the  palms  of  the  hands,  axilla 
and  feet.    It  may  also  be  generalized  as  a  mild  hyperidrosis. 

Flushing  and  high  vascularity  of  the  skin,  "dermotography,"  is  very 
common.  Pulsations  of  the  larger  vessels  of  the  neck  are  quite  notice- 
able and  appear  quite  early. 

Blotchy  erythema,  involving  principally  the  neck  and  upper  chest, 
is  a  common  phenomenon.  The  slightest  excitement  or  manipulation, 
such  as  that  occasioned  by  an  examination,  is  sufficient  to  make  this 
sign  very  noticeable.  Blushing,  which  so  often  occurs  in  exophthalmic 
cases,  is  often  very  annoying,  because  of  the  fact  that  the  slightest 
mental  excitement  will  bring  about  this  condition. 

2.  Edema. — In  a  considerable  number  of  patients  a  localized  edema 
may  be  observed.  It  is  frequently  of  the  fleeting  type,  appearing  sud- 
denly' and  disappearing  within  a  few  hours,  or  it  may  persist  for  days 
or  weeks.  These  edemas  are  usually  of  the  non-pitting  type  and  may 
be  due  to  localized  circulatory  changes,  or  perhaps  are  associated  with 
a  m>ofedematous  tendency.  The  eyelids,  one  or  both,  are  rather  prone 
to  edema,  which  condition  usually  remains  rather  constant. 

3.  Skin. — The  skin  often  reveals  important  phenomena  which  vary 
greatly  in  diflFerent  individuals.  In  some  patients  the  skin  becomes 
thin  and  translucent,  the  finger-nails  crack  and  become  lined  with 
longitudinal  furrows;  the  teeth  become  brittle.  The  hair  becomes 
somewhat  lighter  in  color  and  falls  out.  The  eyelashes  are  the  first 
to  show  the  atrophic  changes,  becoming  short  and  brittle,  and  fall. 

In  some  cases  there  is  a  marked  degree  of  darkening  of  the  skin,  giv- 
ing it  a  smoky  or  dirty  color.  In  others,  especially  in  dark  individuals, 
the  pigmentation  of  the  skin  is  marked,  resembling  the  discoloration 
in  Addison's  disease.  The  areas  about  the  nipples,  axilla,  lower  portion 
of  the  abdomen  and  inner  surfaces  of  the  thighs,  are  usually  darker 
than  the  remaining  portion  of  the  body.  On  the  face  the  most  marked 
portion  is  about  the  eyes  and  is  present  in  a  large  proportion  of  cases. 

]\Ietabolism. — The  general  metabolism  is  aft'ected  to  some  extent: 
the  tendency  to  emaciation  is  not  great,  except  in  the  severe  acute 
cases.  In  many  of  the  mild  cases  the  weight  may  remain  unchanged 
or  may  even  increase.  Temporary  attacks  of  indigestion,  accompanied 
by  vomiting  without  any  apparent  cause,  are  common  in  advanced 


HYPERPLASTIC  TOXIC  GOITER  793 

cases.  Later  a  persistent  vomiting  and  diarrhea  may  occur  and  persist 
indefinitely,  as  either  one  is  seldom  controlled  by  medication.  These 
conditions  are  probably  due  to  the  effect  of  the  toxin  on  the  gastro- 
intestinal tract  and  usually  follow  the  course  of  the  general  manifes- 
tations of  the  disease. 

Blood  Findings. — Kocher^  believes  that  the  blood  picture  is  path- 
ognomonic, so  that  the  diagnosis  can  be  made  from  the  blood  picture 
even  in  abortive  forms  of  the  disease.  His  findings  are  as  follows: 
The  number  of  the  different  varieties  of  normal  leukocytes  undergoes 
alteration,  and  the  number  of  leukocytes,  as  a  whole,  is  slightly 
diminished.  The  neutrophile  leukocytes,  which  are  most  numerous  in 
normal  blood,  are  diminished  to  sometimes  half  their  normal  number, 
so  that  they  may  be  less  numerous  than  the  lymphocytes;  the  latter 
are  increased  sometimes  to  twice  the  normal  number,  and  even  if  there 
is  no  absolute  increase  there  is  always  a  relative  augmentation.  The 
eosinophile  leukocytes  are  usually  also  diminished,  but  may  be  slightly 
increased,  particularly  in  cases  that  are  not  uncomplicated.  The  num- 
ber of  red  cells  is  almost  always  normal,  as  is  also  the  percentage  of 
hemoglobin.  The  viscosity  of  the  blood  is  usually  lowered,  so  that  it 
coagulates  more  slowly. 

Other  observers  in  a  routine  examination  of  the  blood  have  found 
an  increased  IjTuphocytosis,  but  have  not  been  able  to  substantiate 
Kocher's  statement  sufficiently  to  feel  that  the  diagnosis  can  be  made 
from  the  blood  findings  alone. 

Diagnosis. — There  is  no  difficulty  in  the  diagnosis  of  a  typical  case 
of  exophthalmic  goiter.  The  doubtful  cases  are  those  seen  early  in  the 
course  of  the  disease,  especially  when  many  of  the  major  symptoms 
are  wanting.  There  is  perhaps  not  a  single  symptom,  except  possibly 
tachycardia,  which  may  not  be  absent  or  so  inconspicuous  as  not  to 
attract  attention.  If  the  rapid  pulse  is  ever  absent  it  is  extremely  rare, 
but  it  is  not  uncommon  for  the  pulse-rate  to  be  about  ninety  early  in 
the  disease.  It  is  at  times  a  difficult  matter  to  determine  whether  in  a 
young  woman  who  has  a  slightly  enlarged  thyroid,  some  mild  nervous 
manifestation  and  a  rapid  heart  the  picture  is  one  of  an  early  hyper- 
thyroidism, some  psychic  manifestation  or  simply  neurasthenia.  A 
careful  history  and  thorough  examination  will,  however,  usually  dif- 
ferentiate these  conditions.  Persistent  tachycardia,  even  though  not 
marked,  persistent  nervousness,  excitability  and  tremor  not  associated 
with  typical  signs  of  neurasthenia  or  out  of  proportion  of  those  signs, 
persistent  even  though  slight  suffusion  of  the  face,  should  always 
direct  one's  attention  to  the  thyroid,  and  especially  so  if  the  patient 
has  had  an  indolent  goiter  for  several  years.  Fortunately  for  the 
patient  one  or  more  of  the  major  symptoms  will  be  found  in  almost 
every  case  which  will  clear  up  the  diagnosis. 

Treatment.— The  treatment  of  exophthalmic  goiter  may  be  considered 
as  both  surgical  and  non-surgical.    A  great  many  methods  have  been 

^  Keen's  Surgery,  vol.  iii. 


794     DISEASES  OF   THE   THYROID  AND   PARATHYROID  GLANDS 

used  in  the  treatment  of  Graves's  disease,  a  number  of  which  ha\e  had 
enthusiastic  supporters.  The  various  successes  obtained  by  different 
observers  probably  do  not  depend  upon  the  specific  medical  measures 
used  but  on  the  fact  that  a  certain  group  of  cases  suffering  from  Graves's 
disease  will  recover  by  the  well-established  rule  of  rest,  both  mental 
and  physical,  and  the  removal  of  any  foci  of  infection  that  may  be 
present.  There  is  still  another  small  percentage  of  cases  that  will 
recover  from  their  acute  symptoms  without  any  medical  management 
and  remain  in  a  fair  degree  of  health  for  a  long  time.  In  no  other  way 
can  we  explain  why  it  is  that  one  observer  insists  upon  the  importance 
of  the  treatment  of  the  intestinal  tract,  another  on  that  of  the  nervous 
system,  another  on  the  thyroid,  etc.,  with  apparent  cures  occasionally 
from  each  method.  Rest,  above  all,  combined  with  the  treatment  of 
special  symptoms  and  a  well-regulated  diet  is  the  most  important 
element  in  the  non-surgical  treatment  of  exophthalmic  goiter. 

Among  the  many  forms  of  medical  treatment  which  have  been  more 
or  less  successful  may  be  mentioned  the  use  of  quinin  hydrobromate 
and  belladonna,  bromides  and  phosphorus  preparations,  serum  from 
thyroidectomized  goats,  the  Beebe  and  Rogers  serum,  lactic  acid  fer- 
ments, various  injections  into  the  gland  and  .r-ray  exposures.  No  one 
measure  has  given  sufficient  consistent  results  to  make  it  any  more  than 
of  questionable  value. 

In  all  types  of  goiter,  especially  in  children,  the  author  considered  it 
important  to  remove  the  tonsils,  or  any  other  foci  of  infection  that 
may  be  present,  as  a  preliminary  to  whatever  other  treatment  may  be 
contemplated. 

Alvarez^  says  that  the  physician  in  the  absence  of  the  surgeon  can 
do  little  more  for  the  patient  with  exophthalmic  goiter  than  he  could 
in  the  time  of  Parry,  Graves  and  Basedow. 

Surgical  Treatment. — Surgical  interference  is  indicated  in  all  well- 
marked  cases  of  exophthalmic  goiter,  provided  the  patient's  condition 
warrants  it.  Careful  judgment,  however,  is  required  to  determine 
when  to  operate;  just  what  to  do  and  how  much  to  do  in  each  indi- 
vidual case.  The  preoperative  and  postoperative  management  is  also 
of  the  greatest  importance  in  the  surgical  treatment  of  exophthalmic 
goiter. 

In  the  milder  toxic  Cases,  whenever  improvement  from  hygienic, 
dietetic  and  medical  treatment,  together  with  rest,  is  only  of  temporary 
duration,  then  operative  treatment  is  strongly  indicated,  because  in 
these  cases  the  prognosis  is  usually  excellent  if  the  surgical  treatment 
is  employed  before  the  patient  has  suffered  too  many  recurrences.  The 
recoverv  after  surgical  treatment  will  be  much  more  perfect  if  the  opera- 
tion is  performed  before  the  heart  and  other  organs  have  suffered 
severely  from  the  repeated  floodings  of  the  circulation  with  thyroid 
poison.  The  surgical  treatment  of  exophthalmic  goiter  is  based  upon  a 
fairlv  well-established  theory  that  the  symptoms  are  due  to  an  excessive 

'  Quoted  by  Hazzard,  Jour.  Tennessee  State  Med.  Assn.,  September,  1911. 


HYPERPLASTIC  TOXIC  GOITER  795 

secretion  of  an  abnormal  thyroid  which  is  proportionate  to  the  extent 
of  hyperplasia  in  the  gland. 

The  mortality  following  operation  for  exophthalmic  goiter  has  been 
lowered  greatly  in  the  past  few  years.  This  lessened  mortality  is  prob- 
ably due  not  so  much  to  better  methods  of  operating  or  better  skill  as 
to  better  judgment  of  the  proper  time  to  operate.  It  is  not  uncommon 
for  patients  to  be  in  an  extreme  condition  when  they  are  brought  to 
the  surgeon.  Operation  undertaken  upon  such  patients  is  sure  to 
result  in  a  very  high  mortality. 

The  author's  experience  has  been  the  same  as  that  of  C.  H.  Mayo, 
that  is,  that  an  emergency  operation  is  never  called  for  in  exophthalmic 
goiter.  These  cases  practically  never  suffer  from  severe  pressure 
symptoms,  and  in  any  given  case  in  which  the  toxic  condition  is  severe 
enough  to  cause  alarming  symptoms  an  emergency  operation  would 
undoubtedly  result  fatally.  On  the  other  hand  in  many  of  these 
extreme  cases  the  acute  exacerbation  will  subside  under  complete 
mental  and  physical  rest,  when  surgical  treatment  may  be  carried  out 
with  comparative  safety. 

Anesthesia. — The  question  between  general  and  local  anesthesia  is 
still  an  unsettled  one.  Some  authors  consider  general  anesthesia  the 
greatest  danger  in  thyroid  operations,  especially  for  the  relief  of  exoph- 
thalmic goiter,  and  consequently  insist  upon  operating  only  under 
local  anesthesia.  On  the  other  hand,  some  observers  think  that  the 
harm  done  to  the  sensitive  nervous  system  during  the  use  of  local 
anesthesia  is  much  greater  than  the  harm  of  a  carefully  administered 
general  anesthetic.  This  view  is  supported  by  Moebius,  the  author  of 
the  theory  of  hyperthyroidism  in  exophthalmic  goiter. 

For  operating  upon  all  simple  uncomplicated  goiters  and  most  cases 
of  exophthalmic  goiter,  the  writer  has  found  a  properly  administered 
general  anesthetic  to  be  as  safe  and  practical  as  for  other  general 
surgery,  and  considers  it  the  method  of  choice  in  most  cases  of  thy- 
roidectomy. For  this  purpose  ether  should  be  used  and  given  very 
slowly  by  the  open  drop  method,  but  not  to  the  stage  of  profound 
anesthesia.  Local  anesthesia  is  indicated  in  many  cases  of  compli- 
cated goiter  when  there  is  a  marked  tracheal  pressure  in  nephritis  and 
other  general  conditions  that  are  unsafe  under  a  general  anesthetic. 
The  operation  of  ligation  of  thyroid  vessels  may  best  be  done  under 
local  anesthesia.  In  some  nervous,  excitable  patients  with  exoph- 
thalmic goiter,  Crile's  anoci-association  plan  can  be  used  to  advantage, 
which  is  carried  out  as  follows:  (1)  Patients  are  treated  in  the  hospital 
several  days  before  the  operation  is  to  be  performed  and  are  left  in 
ignorance  as  to  the  time  of  operation.  Morphin  and  scopolamin  is 
administered  hypodermicaily  one  hour  before  operation.  (2)  Ether 
or  gas  is  substituted  for  inhalation  of  aromatics,  which  have  been  a 
part  of  the  preparatory  treatment.  (3)  Local  anesthesia  is  used  in 
the  field  of  operation  to  prevent  deleterious  impressions  from  being 
conveyed  to  the  brain,  thus  lessening  the  amount  of  general  anesthetic 
used.    As  a  matter  of  fact,  these  patients  tell  each  other  beforehand 


796    DISEASES  OF   THE   THYROID  AND  PARATHYROID  GLANDS 

concerning  the  method  each  surgeon  is  in  the  habit  of  employing,  so 
that  they  are  as  full}^  informed  about  this  mystery  as  they  are  about 
the  reindeer  that  draw  the  sleigh  that  brings  Saint  Nicholas  and  the 
Christmas  presents,  usually  months  before  the  vicious  thyroid  gland 
is  to  be  taken  away  from  them. 

The  author  uses  the  plan  of  anesthesia  as  advised  by  Ochsner,  which 
is  as  follows:  The  patient  is  given  from  |  grain  to  j  grain  of  morphin, 
together  with  yi^  to  yj^jy  grain  of  atropin,  three-quarters  of  an  hour 
before  the  time  of  operation.  The  preliminary  use  of  the  morphin  and 
atropin  accomplishes  three  things:  (1)  it  has  a  quieting  influence  upon 
the  patient;  (2)  the  quantity  of  ether  required  to  produce  relaxation 
is  reduced  to  a  minimum  and  the  anesthesia  persists  a  considerable 


Fig.  556.— Showing  the  position  of  patient  on  the  table  properly  placed  for  goiter 

operation. 


time  after  the  administration  of  ether  has  been  stopped;  (3)  it  lessens 
the  secretion  in  the  pharynx,  thus  preventing  the  accumulation  of 
mucus  in  the  throat  during  the  operation  from  manipulation  about  the 
trachea. 

The  ether  is  administered  by  the  open-drop  method  until  the  patient 
is  fully  anesthetized,  when  the  patient  is  ready  for  the  operation.  Just 
before  the  operation  is  begun  the  ether  mask  is  removed  and  a  pad, 
composed  of  several  layers  of  sterile  gauze,  is  placed  transversely 
across  the  nose  and  mouth,  preventing  the  patient  from  breathing  or 
coughing  into  the  wound.  The  head  of  the  table  is  now  elevated  and 
the  lower  end  depressed,  so  that  the  patient  is  in  the  inverted  Tren- 
delenburg position  (Fig.  556).     This  results  in  a  sufficient  anemia  of 


HYPERPLASTIC  TOXIC  GOITER  797 

the  brain  so  that  the  operation  can  readily  be  completed  without  the 
administration  of  any  additional  anesthetic.  This  position  has  the 
further  advantage  of  reducing  the  hemorrhage.  In  order  to  keep 
the  respiration  unobstructed  an  assistant  lifts  the  jaw  forward  and  at 
the  same  time  holds  the  gauze  pad  in  place  over  the  mouth.  A  small 
pillow  placed  under  the  shoulders  causes  the  anterior  region  of  the 
neck  to  become  prominent. 

The  advantages  of  administering  ether  in  this  manner  are  several. 
(1)  The  patient  is  relieved  of  all  nervous  and  mental  irritation;  (2) 
the  administration  of  ether  having  ceased  before  the  operation  is 
started,  the  surgeon  can  concentrate  his  entire  attention  upon  the 
operation  itself;  (4)  there  is  no  danger  of  infection  from  the  mouth  or 
by  the  anesthetist  during  the  operation;  (5)  so  small  an  amount  of 
ether  is  used  that  nausea  and  vomiting  rarely  occur;  (6)  it  is  usually 
possible  to  give  these  patients  hot  water  to  drink  almost  immediately 
after  the  operation;  (7)  patients  do  not  inspire  mucus,  which  is  often 
very  troublesome  when  the  anesthetic  is  continued  throughout  the 
operation. 

In  all  cases  of  exophthalmic  goiter,  gastric  lavage  is  practised  imme- 
diately after  the  conclusion  of  the  operation  with  water  at  105°  F. 
This  has  the  effect  of  stimulating  the  patient  and  removing  any  mucus 
or  bile  that  may  have  accumulated  in  the  stomach.  In  cases  suffering 
from  severe  hyperthyroidism  at  the  time  of  operation  the  gastric 
lavage  seems  to  eliminate  postoperative  hyperthyroidism. 

Danger  of  Operation. — 1.  Anesthesia. — Accidents  from  anesthe- 
sia during  operation  upon  the  thyroid  gland  have  not  been  uncommon. 
Many  authors  consider  general  anesthesia  the  greatest  danger,  espe- 
cially in  operation  for  exophthalmic  goiter.  If  general  anesthesia  is 
avoided  in  cases  with  marked  tracheal  pressure,  and  when  used  is  given 
only  to  the  extent  of  light  anesthesia,  or  if  administered  after  the  plan 
of  Ochsner  as  given  above,  accidents  from  anesthesia  will  be  extremely 
rare. 

2.  Postoperative  Hyperthyroidism.  —  The  greatest  real  danger  to 
patients  from  operation  upon  the  thyroid  is  from  postoperative  hyper- 
thyroidism, due  either  to  the  absorption  of  thyroid  secretion  pressed 
out  of  the  gland  into  the  circulation  during  the  operation  or  by  absorp- 
tion of  thyroid  secretion  or  toxic  blood  from  the  wound  surface.  The 
danger  of  postoperative  hyperthyroidism  can  be  eliminated  to  a  great 
extent:  (1)  By  doing  as  rapid  an  operation  as  is  consistant  with  good 
surgery;  (2)  by  avoiding  squeezing  and  rough  handling  of  the  gland 
and  carrying  out  the  entire  operation  with  as  little  trauma  as  possible; 
(3)  by  controlling  hemorrhage  completely,  leaving  the  wound  as  dry 
as  possible;  (4)  by  providing  free  drainage,  so  that  any  oozing  of  the 
blood  and  serum  may  have  easy  escape  and  not  remain  in  contact  with 
the  absorbing  surfaces,  and  by  the  use  of  gastric  lavage  at  the  con- 
clusion of  the  operation  as  indicated  above. 

3.  SJiock. — The  element  of  shock,  which  formerly  was  looked  upon 
as  a  grave  danger  in  goiter  operations,  has  been  practically  eliminated 


798     DISEASES  OF   THE   THYROID  AND   PARATHYROID  GLANDS 

by  the  improved  methods  of  technic.  If  the  surgeon  uses  good  judg- 
ment in  selecting  the  proper  time  to  operate,  especially  in  exoph- 
thalmic cases,  and  then  does  the  operation  with  reasonable  skill, 
avoiding  trauma  of  the  tissues,  and  if  the  vessels  are  secured  before 
they  are  severed,  thus  reducing  the  loss  of  blood  to  a  minimum,  the 
element  of  shock  need  not  be  feared. 

4.  Hemorrhage. — Undue  loss  of  blood  increases  shock  in  three  ways: 
(1)  by  prolonging  the  operation;  (2)  by  increasing  the  amount  of  manip- 
ulation; (3)  by  the  loss  of  blood  itself.  Kocher  claims  that  the  blood 
itself  in  exophthalmic  cases  has  a  considerable  degree  of  toxicity,  so 
that  the  patients  whose  wound  surfaces  have  been  free  from  blood 
make  better  recoveries  than  those  in  whom  the  surfaces  have  been 
drenched  with  blood.  In  avoiding  hemorrhage  it  is  important  to 
remember  that  the  veins  are  thin-walled  and  are  usually  dilated  to 
several  times  their  normal  size.  Great  care  must  be  used  in  securing 
and  ligating  them,  because,  on  account  of  their  size,  a  small  tear 
results  in  a  considerable  loss  of  blood. 

5.  Injury  to  the  Parathyroid  Glands. — Since  the  importance  of  the 
parathyroids  was  generally  recognized,  injury  or  removal  during  opera- 
tion is  extremely  rare,  because  of  the  ease  with  which  they  may  be 
avoided.  The  parathyroids,  four  in  number,  two  on  either  side,  are 
situated  behind  the  capsule  of  the  thyroid.  In  making  the  excision  of 
a  lobe  of  the  th^Toid  its  posterior  capsule  should  be  left  in  position  and 
not  removed  from  the  thvroid.  If  this  one  simple  measure  is  adhered 
to  there  will  be  no  difficulty  in  preserving  the  parath}Toids. 

6.  Injury  to  the  Recurrent  Laryngeal  Nerves. — The  recurrent  laryn- 
geal nerves  lie  posterior  to  the  capsule  of  the  thyroid  along  the  side  of 
the  trachea,  consequently  the  precaution  of  leaving  the  posterior  cap- 
sule of  the  thyroid  will  serve  to  prevent  injury  to  the  nerves  as  well 
as  to  the  parathyroids.  The  danger  of  injuring  the  nerve  while 
securing  the  superior  thyroid  vessels  is  not  great,  as  the  nerve  is  a  con- 
siderable distance  from  the  point  where  the  vessels  enter  the  capsule 
of  the  th;vToid.  At  the  lower  pole  of  the  gland  greater  care  must  be 
used  in  securing  the  inferior  th^Toid  vessels.  If  the  forceps,  grasping 
the  inferior  vessels,  are  placed  forward  on  the  capsule  instead  of  toward 
its  posterior  surface  there  will  be  no  danger  of  injuring  the  nerve. 

7.  Collapse  of  Trachea. — If  the  tracheal  rings  are  normal  there  is  no 
danger  of  collapse  of  the  trachea  during  operation  upon  the  thyroid. 
Occasionally,  from  continued  pressure  by  the  goiter,  a  pressure  atrophy 
of  cartilages  of  the  trachea  takes  place,  resulting  in  a  softening  and 
almost  complete  disappearance  of  the  tracheal  rings.  In  such  cases 
the  trachea  is  likely  to  collapse  as  sooq  as  it  has  lost  its  support  from 
its  attachment  to  the  th\Toid  gland.  When  this  happens  an  immediate 
asphyxia  takes  place,  and  the  more  violent  the  efforts  at  inspiration 
the  more  complete  will  be  the  obstruction.  Attempts  should  be  made 
to  insert  two  sharp  tenaculoe  into  the  collapsed  portion  of  the  trachea 
to  draw  the  latter  forward.  If  this  fails  to  give  relief  a  longitudinal 
incision  should  be  made  in  the  trachea  and  a  tracheotomy  tube  inserted. 


HYPERPLASTIC  TOXIC  GOITER  799 

In  the  removal  of  a  substernal  goiter  there  is  danger  of  asphyxia  from 
pressure  on  the  trachea,  as  the  tumor  is  dislocated  upward. 

8.  Injury  to  the  Pleura. — Occasionally,  during  the  removal  of  sub- 
sternal goiters,  an  opening  is  made  in  the  pleura.  If  this  happens  the 
substernal  space  should  be  packed  immediately  with  a  piece  of  gauze, 
the  end  of  which  is  brought  out  of  the  drainage  opening  in  the  skin  and 
is  left  in  place  for  three  days.  The  author  has  never  seen  any  unfavor- 
able complications  occur  in  these  cases. 

The  selection  of  the  time  to  operate  is  of  the  greatest  importance. 
The  course  of  exophthalmic  goiter  is  one  of  many  periods  of  fluctua- 
tion from  mild  to  almost  moribund  conditions,  and  in  choosing  a  time 
to  operate  the  periods  of  exacerbation  should  be  avoided.  During 
periods  of  exacerbation  all  cases  should  be  considered  as  medical  cases. 
In  many  advanced  cases,  even  in  the  periods  of  slight  remissions,  their 
condition  is  so  extreme  that  they  may  require  careful  medical  prepara- 
tion before  any  surgical  procedure  can  be  carried  out.  All  cases  of 
severe  hyperthyroidism,  when  suffering  from  edema,  dilatation  of  the 
heart,  diarrhea,  vomiting,  etc.,  should  be  under  observation  a  consider- 
able period  to  improve  their  condition  if  possible.  Frequently  patients 
who  at  first  appear  to  be  very  unfavorable  subjects  will  improve  so 
much  under  symptomatic  treatment,  aided  by  rest,  hygiene,  and  the 
x-rays,  as  to  become  fairly  safe  surgical  risks.  In  these  extreme  cases 
of  hyperthyroidism.  Porter  recommends  the  injection  of  boiling  water 
directly  into  the  thyroid  gland  as  being  an  efficient  method  of  preparing 
them  for  operation.  The  writer  has  recently  used  the  boiling  water 
with  satisfactory  results. 

Technic  of  Injection. — An  all-glass  syringe  of  10  to  20  c.c,  supplied 
with  a  rather  fine  long  flexible  needle,  should  be  used.  A  filled  syringe, 
together  with  the  attached  needle,  is  boiled  over  a  gas  or  alcohol  flame 
near  the  bed  or  table.  The  area  to  be  injected  is  first  infiltrated  with 
0.5  per  cent,  novocain.  The  filled  syringe,  which  is  actually  boiling, 
is  taken  from  the  basin  and  the  injection  quickly  made.  From  5  to  20 
c.c.  of  the  boiling  water  are  injected,  according  to  the  size  of  the  gland. 
The  injection  should  be  repeated  every  few  days  until  the  desired  efl'ect 
is  obtained.  Porter^  writes:  "As  to  the  relative  efficiency  of  the  boiling 
water  injection  and  hgation  of  the  vessels  there  seems  to  be  no  longer 
any  reason  for  doubt.  An  injection  of  boiling  water  will  accomplish 
more  than  a  double  ligation  of  the  thyroid  vessels,  and  also  one  can 
accomplish  as  much  by  one  injection  as  can  be  accomplished  by  six 
weeks  to  three  months  of  rest  treatment.  The  relief  following  the 
injection  usually  manifests  itself  within  the  first  twenty-four  to  forty- 
eight  hours,  and  some  patients  show  decided  improvement  in  the 
symptoms  of  tachycardia  and  tremor  immediately.  The  result  of  the 
injection  depends  upon  the  quantity  injected  and  the  kind  of  goiter 
one  is  dealing  with.  Hyperplastic  thyroids  of  pure  type,  whether  the 
hyperplasia  is  diffuse  or  circumscribed,  respond  most  certainly."   C.  H. 

1  Surg.,  Gynec.  and  Obst.,  January,  1915. 


800     DISEASES  OF   THE   THYROID  AND  PARATHYROID  GLANDS 

Mayo^  says:  "Extreme  conditions,  especially  dilatation  of  the  heart, 
may  require  medical  preparation,  and  the  operative  interference 
following  in  cases  resistant  to  treatment  should  be  confined  to  the 
injection  of  boiling  water  into  the  gland  after  Porter's  plan,  to  hasten 
improvement."  Of  the  operative  procedures  for  the  relief  of  exoph- 
thalmic goiter,  that  of  partial  thyroidectomy  is  the  operation  of  choice. 
There  are  a  certain  number  of  cases,  however,  in  which  it  seems  that 
the  risk  of  radical  operation  of  thyroidectomy  is  too  great  even  after 
the  most  careful  preliminary  management.  In  such  cases  the  ligation 
of  the  superior  thyroid  vessels  on  one  side  or  both,  as  a  preliminary 
measure  to  th;yToidectomy,  is  frequently  beneficial.  Occasionally 
it  is  a  difficult  matter  to  decide  upon  just  what  procedure  is  advisable 
in  each  individual  case.  Many  factors  have  to  be  taken  into  considera- 
tion in  deciding  as  to  what  the  patient  may  have  done,  with  reasonable 
safety.  The  degree  of  intoxication  the  cardiac  symptoms,  especially 
in  reference  to  the  amount  of  dilatation,  together  with  the  meatal 
stability,  has  to  be  taken  into  account.  The  severity  of  tachycardia  is 
not  of  so  much  importance  in  determining  what  the  patient  is  able  to 
undergo  as  is  the  amount  of  dilatation  of  the  heart  and  the  degree  of 
mental  involvement.  In  general,  one  may  say  that  whenever  there  is  a 
dilatation  of  the  heart  of  more  than  one  inch  to  the  left  the  risk  of 
thyroidectomy  is  extremely  great.  In  this  class  of  patients  a  pre- 
liminary ligation  of  the  superior  thyroid  vessels  on  one  or  both  sides 
may  reduce  the  production  and  absorption  of  thyroid  poison  to  such 
an  extent  that  the  patient's  general  condition  improves  sufficiently  to 
make  it  safe  to  perform  the  more  extensive  operation  of  thyroidectomy 
a  few  weeks  later.  Many  of  these  extreme  cases  will  improve  greatly 
following  the  ligation  of  vessels,  and  in  the  past  this  operation  was  all 
that  was  deemed  necessary  in  a  certain  group  of  cases.  It  has  been 
the  writer's  experience  that  the  patients  treated  by  simple  ligation 
have  been  very  prone  to  suffer  a  recurrence  of  their  s^inptoms,  conse- 
quently this  procedure  should  be  used  only  in  severe  cases  as  a  pre- 
liminary measure  to  the  operation  of  partial  thyroidectomy.  In  the 
majority  of  cases  the  proper  operative  procedure  can  be  determined 
without  difficulty.  On  the  other  hand  there  are  cases  in  which  this 
caimot  be  determined  definitely  until  after  the  patient  is  brought  to 
the  operating  room.  Occasionally,  on  the  day  of  the  operation,  there 
is  found  to  have  been  an  acute  exacerbation  of  svinptoms  over  the 
preceding  day,  so  that  the  contemplated  surgical  procedure  cannot 
safely  be  carried  out.  Crile^  in  trying  to  prevent  such  phenomena  from 
occurring  at  this  time  endeavors  to  perform  the  operation  without  the 
knowledge  of  the  patient.  The  experience  of  other  surgeons,  how- 
ever, is  that  the  performing  of  surreptitious  operations  is  apparently 
unnecessary. 

Exophthalmic  goiter  patients,  however,  require  special  consideration 
from  the  time  they  enter  the  hospital  until  after  the  operation  is  per- 

1  Collected  Papers,  1913,  p.  567. 
-  Kocher:     Keen's  Surgerj'.  iii,  3()0. 


PLATE    XV 


^up.  Ihjroid  art.  arnH  veJ: 


Posterior  Vie\^^  of  the  Thyroid  Gland. 

Showing  its  eapsiiJe  and  bloodvessels  and  the  relations  to  the  para- 
thyroid bodies  and  recurrent  laryngeal  nerves.  An  anomalous  artery  to 
the  center  of  the  right  lobe  is  shown. 


HYPERPLASTIC  TOXIC  GOITER  801 

formed.  In  the  first  place  it  is  necessary  for  the  surgeon  to  have  the 
complete  confidence  of  the  patient;  second,  it  is  important  that  all 
nurses  and  attendants  should  understand  that  owing  to  the  disturbed 
condition  of  the  nervous  systems  of  these  cases  they  are  likely  to 
become  excited  over  trivial  things,  consequently  extreme  care  must  be 
used,  so  that  nothing  can  occur  which  might  possibly  annoy  them  or 
excite  any  fear.  The  writer  has  found  that  by  proper  cooperation  of 
all  the  attendants  and  by  the  administration  hj^podermically  of  | 
grain  morphin  with  y^^  grain  atropin  even  these  extreme  cases  will 
come  to  the  operating  room  with  no  exacerbation  of  symptoms  over 
the  preceding  day. 

In  almost  all  cases  which  come  to  the  operating  room  with  a  pulse- 
rate  of  120  or  over  there  will  be  a  reduction  of  from  10  to  40  beats  per 
minute  during  the  time  the  patient  is  undergoing  the  operation  if  the 
anesthetic  is  administered  according  to  the  method  described  above. 

Ligation. — There  is  no  doubt  but  that  in  the  questionable  and 
more  severe  cases  the  preliminary  ligation  of  vessels  is  of  value.  The 
operation  is  performed  in  the  following  manner :  These  operations  are 
best  performed  under  local  anesthesia,  which  is  accomplished  by  infil- 
trating the  tissues  with  0.5  per  cent,  novocain  solution,  to  which  has 
been  added  a  small  amount  of  adrenalin  chloride  solution.  The  sub- 
cutaneous  tissues,  as  well  as  the  skin,  should  be  infiltrated.  Novocain 
is  non-toxic  and  0.5  per  cent,  solution  can  be  used  very  freely,  resulting 
in  the  advantage  that  a  wide  infiltration  of  the  operative  field,  with 
liberal  nerve  blocking,  can  be  efi^ected.  After  the  operative  field  has 
been  anesthetized  an  incision  is  begun  at  about  the  middle  of  the 
thyroid  cartilage  and  extended  outward  a  distance  of  about  one  and 
a  half  inches,  following  one  of  the  natural  lines  of  the  neck  if  possible. 
The  incision  is  carried  down  through  the  skin,  superficial  fascia  and 
platysma  muscle.  Retractors  are  now  placed,  separating  these  struc- 
tures in  the  direction  of  the  long  axis  of  the  body.  The  anterior  border 
of  the  sternocleidomastoid  muscle  is  now  exposed  and  is  retracted 
outward.  The  superior  thjToid  vessels  are  now  exposed  by  dissecting 
free  the  anterior  belly  of  the  omohyoid  muscle  and  retracting  it  upward 
and  inward.  By  means  of  a  ligature  carrier  a  linen  or  silk  ligature  is 
passed  around  the  thyroid  vessels  close  to  or  including  the  upper  pole 
of  the  gland.  There  need  be  no  fear  of  injuring  the  nerve,  as  the  liga- 
tion is  made  between  the  superior  and  the  inferior  larnygeal  nerves. 
The  wound  is  closed  without  drainage.  If  after  one  side  has  been 
ligated  the  patient's  condition  is  good  a  ligation  of  the  superior  vessels 
may  be  made  on  the  opposite  side  at  the  same  sitting.  In  the  extreme 
cases  it  is  safer  to  make  only  a  single  ligation  and  note  the  reaction. 
If  not  much  reaction  follows  it  is  usually  safe  to  do  a  thyroidectomy  a 
week  or  t^^o  following.  On  the  other  hand  if  much  reaction  follows  the 
single  ligation  it  is  better  to  make  a  ligation  of  the  opposite  side  one 
week  later  and  delay  the  thyroidectomy  for  several  weeks.  Ligation 
of  the  inferior  thyroid  vessels  is  difficult  and  cannot  be  accomplished 
safely  without  first  elevating  the  goiter.    It  is  therefore  not  a  practical 

VOL.  I 51 


802     DISEASES  OF   THE   THYROID  AND   PARATHYROID  GLANDS 

procedure,  because  the  risk  is  practically  as  great  as  when  combined 
with  immediate  excision. 

In  extreme  cases  even  the  operation  of  simple  ligation  of  the  superior 
thyroid  vessels  on  one  side  is  not  without  considerable  danger.  The 
postoperative  treatment  is  important.  These  })atients  must  have 
absolute  quiet  and  should  be  kept  in  a  semisitting  posture,  be  given 
water  per  rectum  by  the  continuous  drop  method,  or  if  this  is  not 
retained  well,  normal  salt  solution  should  be  administered  by  hypo- 
dermoclysis.  ]\Iorphin  and  bromides  may  be  used  to  advantage  and 
occasionally  some  of  the  preparations  of  strophanthus.  The  most 
important  of  these  measures,  however,  are  physical,  mental  and 
emotional  rest  and  the  large  quantities  of  water.  Quite  marked 
improvement  is  reasonably  certain  to  follow  ligation,  which  is  evidenced 
by  signs  of  lessened  toxemia  in  every  way.    In  double  ligation  the  height 


Platysma 


Sternohyoid  and 
sternothyroid  nius. 


Ext.  capsule 
of  thyroid 


Int.  capsule 
of  thyroid 


Bloodvessels *-  -v 


Prevertebral  - 
fascia 


Sternocleido- 
mastoid 
muscle 


Omohyoid 
muscle 


Int.  jugular 
vein 

Com.  car- 
olid  art.  and 
vagus  nerve 

Parathyroid 


Longv^  colli  muscle  Esophagus 

Fig.  557. — Transverse  section  through  the  thyroid  gland.      (After  Corning.) 


of  improvement  is  usually  reached  in  from  twelve  to  sixteen  weeks, 
at  which  time  the  operation  of  thyroidectomy  may  be  done  with  com- 
parative safety.  During  this  period  following  the  ligation  of  the 
thyroid  vessels  the  patient  usually  gains  considerably  in  weight  and 
assumes  a  more  nearly  normal  appearance,  loses  much  of  her  nervous 
irritability  and  feels  that  she  has  actually  recovered  from  a  serious 
illness. 

Thyroidectomy. — Incision. — The  incision  should  be  made  so  as  to 
give  a  free  exposure  of  all  the  structures  encountered  during  the  opera- 
tion and  also  result  in  little  or  no  deformity  after  the  wound  is  healed. 
Free  access  to  the  operative  field  is  important  in  order  that  various 
important  structures  can  be  protected  during  the  operation  and  the 
loss  of  blood  and  traumatism  be  reduced  to  a  minimum. 

As  all  the  muscles  of  the  neck  are  arranged  in  pairs  it  is  plain  that  in 


HYPERPLASTIC  TOXIC  GOITER 


803 


order  to  avoid  deformity  from  the  scar  the  incision  must  be  symmet- 
rical. The  best  incision  to  accompHsh  these  conditions  is  the  one 
introduced  by  Kocher,  and  called  by  him  "the  collar  incision,"  as 
shown  in  Fig.  559.  The  incision,  which  is  carried  down  through  the 
skin  and  platysma,  begins  at  one  external  jugular  vein,  following  a 
gradual  curve  downward  across  the  neck  and  up  to  a  corresponding 
point  on  the  opposite  side,  its  center  being  about  3  cm.  above  the 


capsule 

thyroid . 


Portion  of  fhyroid 
tissue  not  removed. 


Fig.  558. — Left  lobe  removed,  showing  remaining  thyroid  tissue  protecting  posterior 
part  of  its  capsule.     Forceps  placed  upon  upper  and  lower  poles  of  right  lobe. 


upper  margin  of  the  sternum.  The  skin  and  platysma  are  dissected 
upward,  exposing  the  sternohyoid  muscles.  In  making  this  dissection 
care  should  be  used  not  to  injure  the  anterior  jugular  vein  and  numerous 
smaller  veins,  all  of  which  are  often  quite  large.  By  a  vertical  incision 
between  the  two  anterior  jugular  veins  the  sternohyoid  and  sterno- 
thyroid muscles  are  separated.  This  incision  should  include  the  external 
fibrous  capsule  over  the  gland.  Lateral  traction  is  made  on  either  side 
by  retractors,  drawing  outward  the  sternohyoid  and  sternothyroid 


804     DISEASES  OF   THE   THYROID  AND   PARATHYROID  GLANDS 

muscles,  making  a  complete  exposure  of  the  goiter.  In  most  simple 
goiters  and  also  in  some  exophthalmic  goiters  the  goiter  can  be  removed 
easily  through  this  exposure  without  cutting  any  of  the  muscles.  In 
many  large  goiters  and  in  most  exophthalmic  goiters  this  does  not  afford 
sufficient  space  for  easy  removal.  In  such  cases  it  is  necessary  to  cut 
off  the  sternohyoid  muscles  before  proceeding  further  with  the  opera- 
tion. The  section  of  these  muscles  is  made  as  high  up  as  possible, 
so  that  when  reunited  the  nerve  supply  has  been  preserved  and  the 
muscles  and  cutaneous  scars  separated,  preventing  a  muscle-drawn 
scar,  which  moves  up  and  down  during  deglutition.  Two  hemostatic 
forceps  are  placed  across  the  sternohyoid  and  sternothyroid  muscles 


Fig.  559. — Showang  the  incision  closed  with  horsehair  sutures.     A  Kocher  glass  tube 
and  a  piece  of  formaline  gauze  are  pressed  through  the  puncture  wounds  as  drains. 

high  up,  but  locked  loosely  so  as  not  to  crush  the  muscles.  The  forceps 
should  be  placed  about  1  cm.  distant  from  each  other,  so  that  when  the 
muscles  are  cut  between  them  they  will  not  slip  from  the  forceps. 
By  gently  passing  the  finger  between  the  thyroid  gland  and  the  sur- 
rounding structures  it  is  easily  separated  except  for  its  posterior 
attachments.  While  the  gland  is  rolled  forward  by  gently  raising 
with  the  hand  and  kept  at  slight  tension,  the  lateral  veins,  which  can 
be  readily  seen,  are  caught  with  two  pairs  of  forceps  and  divided 
between.  The  superior  th;yToid  vessels  are  now  caught  between  for- 
ceps, which  also  grasp  the  corner  of  the  upper  pole  of  the  gland.  Three 
forceps  should  be  used  in  order  to  avoid  slipping,  two  placed  proximal 


HYPERPLASTIC  TOXIC  GOITER  805 

and  one  distal  to  the  point  where  the  vessels  are  to  be  severed.  The 
anastomosing  vessels  from  the  isthmus  are  caught  in  the  same  manner. 
While  the  gland  is  still  held  in  this  position,  three  forceps  are  applied 
to  the  lower  pole  of  the  gland,  grasping  the  inferior  vessels  in  the  same 
manner  as  the  superior.  Care  should  be  used  in  placing  the  forceps 
well  forward  to  avoid  injury  of  the  nerve  which  crosses  the  inferior 
vessels  just  below  the  lower  pole  of  the  gland  posteriorly.  By  grasping 
a  small  portion  of  the  lower  pole  in  these  forceps,  being  sure  to  keep 
in  front  of  its  posterior  capsule,  the  nerve  cannot  be  injured.  It  is 
not  uncommon  to  encounter  an  artery  of  considerable  size  entering 
the  gland  near  its  center  posteriorly.  This  is  usually  a  branch  of  the 
inferior  thjToid  artery  called  the  middle  thyroid.  In  a  number  of 
cases  there  is  still  another  artery,  the  arteria  thyreoidea  ima,  usually 
only  on  one  side.  It  is  a  direct  branch  of  the  innominate  artery  and 
runs  to  the  thyroid  isthmus.  These,  if  present,  are  caught  and  ligated 
between  the  isthmus  and  the  gland,  near  its  upper  and  lower  poles, 
and  should  be  caught  between  clamps  and  cut.  An  incision  is  now  made 
through  the  thjToid  capsule  along  its  lateral  border  and  forceps  are 
applied  along  the  edge  of  the  capsule  posteriorly.  The  gland  is  now 
dissected  forward  toward  the  trachea,  leaving  the  posterior  capsule 
of  the  thyroid  in  its  normal  position  in  the  neck,  thus  ensuring  protec- 
tion to  both  the  nerve  and  the  parathyroid  glands.  As  the  dissection 
is  made,  any  small  vessels  encountered  are  clamped.  If  more  than  one 
lobe  is  involved  it  may  be  necessary  to  remove  the  isthmus,  together 
with  one  lobe,  or  both  the  isthmus  and  a  portion  of  the  remaining  lobe. 
To  accomplish  this  the  first  lobe  as  it  is  dissected  from  the  posterior 
capsule  and  rolled  inward  across  the  trachea  is  left  attached  to  the 
isthmus  while  this  part  of  the  dissection  is  made.  In  making  the  dis- 
section of  the  isthmus  one  must  be  careful  not  to  injure  the  trachea, 
which  is  exposed  at  this  point.  In  advanced  cases,  or  in  patients  who 
have  very  hard  nodules  pressing  upon  the  trachea,  some  of  the  tracheal 
rings  may  have  been  softened,  so  that  when  the  isthmus  is  removed 
there  is  not  enough  support  for  the  softened  trachea,  and  the  latter 
collapses  during  each  inspiration,  causing  sudden  asphyxia.  An  incu- 
bation tube  or  tracheotomy  tube  should  be  at  hand,  so  that  if  necessary 
the  asphyxia  can  be  relieved  at  once.  Fortunately,  this  accident  does 
not  often  happen.  A  resection  of  the  remaining  lobe  is  accomplished 
in  the  same  manner  as  described,  except  that  after  the  inferior  and 
lateral  vessels  have  been  clamped  and  severed  as  in  complete  removal 
of  the  first  lobe,  the  branches  of  the  superior  vessels  are  grasped  on 
the  surface  of  the  gland,  together  with  the  capsule  at  the  point  where 
the  section  of  the  gland  is  to  be  made.  Considerable  oozing  takes  place 
from  the  cut  surface  where  section  has  been  made.  This  is  best  con- 
trolled by  whipping  together  the  cut  end  of  the  gland  by  means  of  a 
catgut  sutiu-e.  More  blood  is  liable  to  be  lost  during  the  resection  of 
a  lobe  than  from  complete  removal,  for  in  the  latter  practically  all  the 
vessels  can  be  clamped  before  they  are  severed. 

The  amount  of  th^Toid  tissue  to  be  left  varies  according  to  the  type 


806     DISEASES  OF  THE   THYROID   AND   PARATHYROID  GLANDS 

of  goiter.  The  more  toxic  the  case  the  smaller  the  amount  of  thAToid 
tissue  that  need  be  left.  In  general  the  p^eser^-ation  of  a  portion  of 
thyroid  tissue  in  simple  goiter  equal  to  one-half  the  normal  gland,  and 
in  exophthalmic  goiter  equal  to  one-sixth  or  one-fourth  will  probably  be 
sufficient  to  prevent  myxedema.  In  simple  goiters  only  a  few  forceps 
are  required,  or  practically  all  the  hemorrhage  is  controlled  by  the 
application  of  the  few  forceps  described  above. 

The  technical  difficulties  in  removing  exophthalmic  goiter  are  usually 
much  greater  than  in  simple  goiter,  because  of  the  fact  that  in  these 
cases  the  gland  is  very  vascular  and  friable  and  its  capsule  is  adherent. 
The  bloodvessels  are  very  numerous  and  their  walls  brittle,  making 
it  necessary  to  be  very  gentle  in  catching  and  ligating  them.  While 
only  a  few  forceps  are  necessary  in  ^emo^  al  of  a  simple  goiter,  many 
dozen  may  be  required  in  some  exophthalmic  cases.  Care  should  be 
used  in  placing  ligatures  securely,  especially  those  applied  to  the 
superior  and  inferior  poles  of  the  gland,  so  that  there  will  be  no  danger 
of  their  slipping  off  during  coughing  or  struggling  while  the  patient  is 
recovering  from  the  anesthetic.  It  is  important  that  the  loss  of  blood 
during  the  operation  be  reduced  to  the  minimum,  and  especially 
important  at  the  close  of  the  operation  to  see  that  all  oozing  surfaces 
are  controlled,  leaving  the  wound  as  dry  as  possible.  Kocher  believes 
there  is  a  certain  amount  of  specific  toxicity  in  the  blood  in  these  cases, 
which  if  left  in  contact  with  the  wound  surface  can  be  absorbed, 
producing  acute  toxic  symptoms. 

Drainage. — Efficient  drainage,  especially  in  exophthalmic  goiter,  is 
necessary  in  order  to  prevent  absorption  of  blood  or  thAToid  secretion 
from  the  wound  surfaces.  The  method  used  should  be  one  that  will 
ensure  immediate  drainage  at  all  times.  For  this  purpose  we  have 
found  the  drain  used  by  Ochsner  to  be  very  efficient.  It  is  a  combined 
drain,  composed  of  a  layer  of  gauze  loosely  packed  into  the  wound 
area  from  which  the  th\Toid  has  been  removed,  with  the  additional 
introduction  of  a  small  glass  drainage  tube,  both  of  which  are  brought 
out  of  the  neck  through  a  small  stab  wound  below  the  original  incision, 
as  shown  in  Fig.  559.    Drainage  is  left  in  place  fort}'-eight  hours. 

Closure  of  the  Wound. — If  it  has  been  necessary  to  section  the 
sternohyoid  and  sternothyroid  muscles  the  cut  ends  should  be  united 
carefully  with  a  running  catgut  suture.  The  separated  sternohyoid  and 
sternothyroid  muscles  on  either  side  are  now  brought  together  in  the 
midline  by  catgut  sutures.  The  skin  should  be  closed  in  a  manner  to 
leave  the  least  scar.  A  satisfactory  method  consists  of  first  placing 
several  subcuticular  fine  catgut  sutures  along  the  line  of  incision  at 
regular  intervals,  uniting  the  platysma  muscles  and  the  subcutaneous 
fascia.  This  will  remove  all  tension  from  the  skin  proper,  which  is  now- 
approximated  by  placing  horsehair  sutiu-es,  drawn  just  tightly  enough 
to  secure  accurate  coaptation,  but  not  to  cause  any  cutting.  If  these 
sutures  are  applied  loosely  and  are  removed  on  the  fifth  day  there  will 
remain  no  marks  from  their  use. 


MALIGNANT  GROWTH  OF  THE  THYROID  GLAND 


807 


MAUGNANT  GROWTH  OF  THE  THYROID  GLAND. 

Carcinoma  and  sarcoma  may  both  occur  in  the  thyroid,  the  former 
being  much  more  common  than  the  latter.  Unfortunately,  both  of 
them  are  usually  hopeless  so  far  as  treatment  is  concerned,  because 
they  are  usually  far  advanced  when  the  diagnosis  is  made.  Occasion- 
ally, in  thyroids  which  have  been  removed  for  relief  of  simple  goiter, 
the  postoperative  microscopic  examination  has  revealed  the  presence 
of  carcinoma,  and  some  of  these  patients  have  remained  free  from 
recurrence,  because  the  growth  had  not  extended  beyond  the  limits  of 
the  gland.  An  attempt  should  be  made  to  make  an  early  diagnosis  in 
these  cases. 


Fig.  560. — Showing  the  healed  incision  after  partial  excision  of  a  large  goiter.  This 
woman  had  symptoms  of  severe  intoxication  and  was  emaciated  as  one  can  see  by  the 
prominence  of  the  clavicle.  The  drain  wound  is  still  red  and  shiny  but  after  a  time 
this  all  disappears. 


Diagnosis. — The  early  diagnosis  is  based  upon  the  history  and  local 
physical  findings.  The  growth  of  a  malignant  goiter  is  irregular. 
While  many  simple  goiters  are  irregular,  in  malignant  goiter  one  or 
more  nodules  will  grow  out  from  the  main  mass  and  become  more 
distinctly  palpable.  If  any  patient  over  thirty-five  years  of  age  who 
has  had  a  goiter  for  several  years  notices  that  the  gland  is  enlarging 
without  any  apparent  cause,  malignancy  should  be  suspected.  If  this 
enlargement  be  irregular  in  outline  and  upon  examination  is  found  to 
be  firmer  than  the  rest  of  the  gland,  losing  its  elasticity,  the  diagnosis 
may  be  fairly  certain.  The  bloodvessels  over  the  region  of  the  gland 
are  found  to  be  abnormally  well  developed,  although  there  is  not  at 
all  a  characteristic  sign.  Displacement  of  the  surrounding  parts  is 
irregular,  because  the  growth  often  increases  only  on  one  side.  On 
account  of  the  irregular  development  and  the  early  development  of 


808     DISEASES  OF  THE   THYROID   AND   PARATHYROID  GLANDS 

adhesions,  slight  pressure  signs  develop  early,  characterized  by  change 
in  the  voice,  local  signs  of  venous  obstruction  and  slightly  impaired 
mobility  of  the  head  or  neck.  A  careful  history  will  often  elicit  these 
signs  early  in  the  disease.  All  other  symptoms,  such  as  pain,  dysphagia, 
cachexia  and  loss  of  weight,  only  occur  later  after  the  disease  has 
advanced  to  a  hopeless  degree.  Metastases  occur  comparatively  early 
in  the  disease.  Unfortunately,  it  is  rarely  possible  to  obtain  a  perma- 
nent cure  in  cases  in  which  positive  diagnosis  of  a  malignant  growth 
can  be  made  before  the  operation. 


Fiu.  561. — Sarcoma  of  thyroid  resembling  in  gross  outline  a  large  colloid  goiter. 


Treatment. — Early  operation  ofll'ers  the  only  hope  of  r.eli€f_in  malig- 
nant condition,  but,  unfortunately,  many  of  these  conditions  are  not 
recognized  until  the  patient  has  reached  a  hopeless  condition.  Opera- 
tion is  contra-indicated  in  the  presence  of  pietastases,  and  when  the 
growth  has  perforated  the  capsule,  making  it  so  adherent  to  the  sur- 
rounding structures  as  to  render  its  complete  removal  impossible. 
Occasionally,  treatment  is  required  to  relieve  the  terrible  sufferings 
from  dyspnea,  with  impending  asphyxia.  This,  however,  is  often  a 
difficult  matter  to  do,  because  the  operation  of  tracheotomy  in  the 
presence  of  a  malignant  goiter  is  one  of  the  most  difficult  operations 
to  accomplish.  It  is  often  impossible  to  do  without  first  removing  a 
portion  of  the  goiter. 

Malignant  goiter  usually  involves  only  one  lobe  of  the  thyroid 
primarily,  and  if  the  diagnosis  is  made  before  the  growth  has  invaded 
the  capsule  the  immediate  prognosis  is  scarcely  more  grave  than  in 
the  operation  for  simple  goiter.  The  operation  should  consist  of  com- 
plete incision  of  the  entire  thyroid  with  the  capsule,  even  to  the  extent 
of  endangering  the  parathyroids  and  nerve  on  the  involved  side.  The 
author  has  one  patient  well  ten  years  after  removal  of  the  thyroid  for 


POSTOPERATIVE  TREATMENT  809 

carcinoma,  and  two  other  patients  are  apparently  well  several  months, 
one  of  these  being  a  localized  carcinoma  in  a  substernal  goiter  from  the 
lower  pole  of  the  left  lobe  of  the  thyroid.  In  this  case  there  was  a 
complete  excision  of  the  left  lobe  together  with  its  capsule  and  para- 
thyroids. The  right  lobe  was  not  disturbed,  as  it  appeared  normal 
both  in  size  and  structure.  This  patient  has  exjiibited  no  signs  of  tetany. 

POSTOPERATIVE  TREATMENT. 

In  advanced  cases  of  hyperthyroidism  much  may  depend  upon  the 
after-treatment.  The  patient  should  be  placed  in  the  semisitting  pos- 
ture, with  an  ice-bag  over  the  precordial  region.  Immediately  after 
the  operation  it  is  important  to  supply  an  abundance  of  liquid  to  the 
patient  by  giving  hot  water  by  mouth  and  the  administration  of  normal 
saline  solution  per  rectum  by  the  continuous  drop  method.  In  the 
majority  of  cases,  liquids  administered  in  this  manner  will  be  sufficient, 
but  if  the  patient  exhibits  signs  of  postoperative  hyperthyroidism, 
1000  c.c.  of  salt  solution  should  be  administered  by  hypodermoclysis 
and  repeated  every  eight  hours  until  the  symptoms  subside. 

Ochsner  has  recently  recommended  repeated  gastric  lavages  as  an 
important  aid  in  lessening  the  postoperative  toxicity  in  severe  exoph- 
thalmic cases.  He  has  found  repeatedly  that  patients  with  extreme 
symptoms  of  hyperthyroidism  would  invariably  be  immediately 
improved  by  a  gastric  lavage.  The  author  believes  that  by  the  com- 
bined use  of  repeated  saline  transfusion  and  gastric  lavages  a  certain 
number  of  extreme  cases  can  be  gotten  well  that  otherwise  would  result 
fatally.  The  use  of  opium  in  some  form,  combined  with  sodium 
bromide  administered  per  rectum,  is  often  a  great  aid  in  securing  rest 
in  the  very  restless  cases. 

After-treatment. — Owing  to  the  fact  that  in  the  majority  of  patients 
suffering  from  toxic  goiter  for  any  considerable  time  a  certain  amount 
of  permanent  injury  has  occurred  to  vital  organs,  it  is  important  to 
give  these  patients  definite  directions  as  to  their  habits  and  mode  of 
living  for  an  indefinite  period.  This  is  essential  not  only  to  reestablish 
their  health  and  strength,  but  also  to  maintain  this  after  it  has  been 
established.  While  the  majority  of  these  patients  recover  sufficiently 
to  be  able  to  lead  fairly  comfortable,  useful  lives,  they  are  not  in  a 
condition  to  compete  with  the  average  individual  and  indulge  in 
physical,  mental,  emotional  and  dietetic  excesses.  We  make  it  a  rule 
to  give  all  patients  who  have  suffered  from  toxic  goiter  a  printed  list 
of  instructions  to  follow  for  a  definite  time  after  they  return  to  their 
homes,  and  emphasize  thoroughly  the  fact  that  the  permanency  of  their 
cure  depends  largely  upon  the  care  with  which  they  carry  out  these 
directions.  The  directions  briefly  summarized  are:  Avoid  overwork, 
excitement,  alcohol,  tobacco,  tea  and  coffee,  social  and  business  worries 
and  to  select  diet  composed  largely  of  milk,  cooked  vegetables,  cereals 
and  fruits. 


810     DISEASES  OF  THE    THYROID    AND   PARATHYROID  GLANDS 

SURGICAL  IMPORTANCE  OF  THE  PARATHYROIDS. 

AVhile  our  knowledge  of  the  parathyroids  is  very  meager,  it  is 
evident  that  these  glands  possess  a  function  that  is  essential  for  the 
normal  metabolism.  Considerable  animal  experimentation  has  been 
done  with  the  parathyroids,  and  one  fact  has  been  established,  and  that 
is,  that  removal  of  the  parathyroids  is  followed  by  a  condition  termed 
experimental  tetany. 

Tetany  following  operation  of  thyroidectomy  is  undoubtedly  due 
to  removal  or  injury  to  the  parathyroid  tissue.  It  is  important,  there- 
fore, that  the  surgeon  use  the  utmost  care  to  guard  against  removal  or 
injury  to  these  structures.  Owing  to  the  fact  that  they  are  situated 
behind  the  posterior  capsule  of  the  thyroid  gland,  their  injury  is  not 
likely  if  one  remains  in  front  of  the  capsule  during  the  dissection  or 
removal  of  the  thyroid.  The  surgeon  should,  however,  bear  in  mind 
the  size  and  appearance  of  the  parathjToids,  and  if  any  small  gland- 
like masses  about  the  capsule  should  have  been  accidentally  removed 
during  the  operation,  they  should  be  implanted  at  some  point  back 
of  the  capsule  of  the  thyroid. 

At  the  present  time  there  is  no  reliable  treatment  for  tetany.  Assum- 
ing that  the  condition  is  due  to  deficient  parathyroidal  tissue,  the 
treatment  indicated  would  be  an  attempt  to  make  up  the  deficiency  by 
transplanting  parathyroids  from  other  persons,  the  use  of  serum  or 
the  extract  of  parathyroid,  and  the  administration  of  calcium  salts  to 
restore  the  balance  in  calcium  metabolism.  All  of  these  measures 
have  been  used,  but,  unfortunately,  have  not  given  uniformly  satis- 
factory results. 

In  two  cases  of  tetany  following  thyroidectomy  we  have  administered 
10  grains  of  calcium  lactate  every  hour  for  a  few  days,  then  every  two 
and  later  every  three  hours,  then  four  times  each  day  for  two  months. 
Both  of  these  cases  recovered  fully,  but  it  is  difficult  to  say  whether  this 
W'as  a  coincidence  or  whether  the  recovery  was  due  to  the  remedy. 
In  both  cases  the  contractions  of  the  muscles  ceased  shortly  after 
beginning  the  administration  of  the  remedy  and  commenced  again 
when  the  remedy  was  temporarily  abandoned,  only  to  disappear  again 
when  the  remedy  was  again  administered. 


THE  DUCTLESS  GLANDS. 


By  GEORGE  W.  CRILE,  M.D.,  F.A.C.S. 

Research  and  clinical  experience  are  rapidly  accumulating  evidence 
that  the  interaction  of  the  ductless  glands  by  means  of  their  secretions 
or  hormones  has  a  vital  bearing  upon  the  welfare  of  the  organism  and 
that  these  secretions  play  an  important  role  in  certain  pathologic 
conditions.  The  preeminent  example  of  such  a  far-reaching  organic 
effect  is  presented  by  the  role  of  the  thyroid  in  exophthalmic  goiter; 
while  the  interaction  of  the  different  glands  is  well  exemplified  by  the 
increased  activity  of  the  adrenals  in  the  same  disease,  in  which  the 
increased  adrenal  secretion  in  turn  probably  increases  the  thyroid 
activity. 

Surgery  has  defined  the  relation  of  the  thyroid  to  exophthalmic 
goiter  and  as  a  result  has  established  the  operative  treatment  for 
exophthalmic  goiter  as  securely  as  the  operative  treatment  of  diseases 
of  the  gall-bladder  or  of  the  pelvic  organs.  In  the  light  which  has  thus 
been  thrown  upon  this  disease  it  is  apparent  that  every  part  of  the 
organism  is  affected,  and  a  resultant  profound  alteration  in  metab- 
olism produced. 

The  drive  in  exophthalmic  goiter  could  scarcely  have  been  initiated 
by  the  thyroid.  It  would  seem  rather  that  the  thyroid  is  driven  by 
other  forces;  for  example  by  the  nervous  system  directly  through  the 
innervation  of  the  thyroid  cells,  and  the  innervation  of  the  bloodvessels 
of  the  thyroid.  According  to  Cannon  the  thyroid  is  stimulated  by 
adrenalin.  It  seems  doubtful  whether  exophthalmic  goiter  could  origi- 
nate under  conditions  of  subnormal  impulses  or  in  the  presence  of  a 
subnormal  amount  of  adrenalin.  With  this  view  of  the  thyroid  and  the 
adrenals  as  tT\^o  demonstrable  interactive  links  in  the  kinetic  system, 
we  shall  in  the  main  confine  our  discussion  to  a  consideration  of  the 
specific  role  of  each. 


THE  THYEOID. 

The  chief  role  of  the  thyroid  seems  to  be  that  of  increasing  the 
metabolism  of  various  organs  and  tissues.  It  does  not  appear  that  the 
thyroid  specifically  influences  the  function  of  any  one  organ  more  than 
another.  There  is  no  evidence  that  the  thyroid  influences  in  any 
degree  the  procreative,  the  physical  self-defensive,  or  the  chemical 
self-defensive  mechanisms  as  such — but  it  intensifies  their  respective 
actions  when  these  mechanisms  are  integrated  for  increased  activity. 

If  the  thyroid  has  no  selective  influence  upon  any  specific  organ  how 

(811) 


812  THE  DUCTLESS  GLANDS 

can  we  explain'the  fact  that  in  myxedema  there  is  diminished  sexual 
excitation,  and  conception  does  not  occur?  First  of  all,  it  should  be 
remembered  that  animals  whose  ovaries  have  been  removed  early  in 
life  have  no  sexual  desires.  ]\Iale  animals  which  have  been  castrated 
in  early  life  have  no  sexual  desire.  From  these  facts  we  may  infer,  at 
least  as  far  as  sexual  life  is  concerned,  that  the  generative  organs 
receive  the  sex  stimulus,  and  these  organs  in  turn  indirectly  excite  the 
thyroid  to  activity.  The  resultant  secondary  thyroid  stimulation 
increases  oxidation. 


HYPERPLASIA  OF  THE  THYROID— GOITER. 

How  is  the  thyroid  enlargement  so  frequently  seen  in  adolescence 
to  be  interpreted?  The  secondary  sexual  characters  will  not  develop 
unless  the  sex  organs  are  developed,  and  neither  will  they  develop  in  the 
absence  of  the  thyroid.  The  loss  of  the  sex  organs  prevents  sex  differ- 
entiation only;  the  loss  of  the  th>Toid  prevents  all  development  impar- 
tially. We  conclude,  therefore,  that  the  thyroid  influence  is  an  essential 
basis  upon  which  sex  differentiation  depends.  For  this  reason,  during 
the  period  of  active  sex  differentiation,  the  thyroid  is  called  upon  to 
increase  its  activity.  We  may  suppose  that  when  the  normal  thyroid 
gland  is  unable  to  meet  the  increased  demands  made  upon  it  in  the 
period  of  adolescent  development  it  undergoes  h^^erplasia. 

If  iodin  is  given  during  this  period  hjT^erplasia  will  not  result. 
Moreover,  ]\Iarine  has  shown  that  if  iodin  or  thyroid  extract  be  given 
over  a  sufficient  period  the  hyperplasia  reverts  to  the  colloid  type. 

It  is  not  only  during  adolescence  or  as  the  result  of  sexual  activa- 
tion that  the  thyroid  enlarges.  It  not  infrequently  enlarges  in  the 
presence  of  infection.  As  the  mechanism  of  the  production  of  fever 
requires  increased  oxidation,  the  thyroid  is  driven  to  greater  activity, 
and  hj'perplasia  may  result  according  to  the  ability  of  the  gland  to 
meet  the  additional  demands  upon  it.  In  these  cases  also  if  iodin  be 
given,  hyperplasia  will  not  result. 

In  like  manner  we  may  suppose  the  constant  stimulation  of  the 
thyroid  from  the  absorption  of  toxins  from  the  intestines  causes 
hyperactivation  of  the  thyroid  with  the  resultant  tendency  to  hyper- 
plasia. Since,  as  we  have  indicated  above,  the  participation  of  the 
thyroid  in  the  response  to  infection,  to  sex  stimulation,  to  auto- 
intoxication is  secondary,  through  the  nervous  system  which  received 
the  primary  activation,  the  secondary  participation  of  the  thyroid 
through  the  nervous  system  in  the  activation  produced  by  fear,  by 
anger,  by  worry,  by  overwork,  and  the  resultant  hyperplasia,  is  under- 
stood. 

As  stated  above,  hyperplasia  of  the  thyroid  may  be  produced  by 
any  of  the  factors  that  sufficiently  activate  the  kinetic  system.  This 
hyperplasia  may  subside  when  the-  cause  is  removed  and  the  gland 
reverts  to  its  nonnal  state  or  the  gland  may  remain  permanently 
enlarged — thus  gradually  building  up   a  goiter. 


MYXEDEMA  813 

ADENOMATA— THYREOTOXICOSIS. 

The  symptoms  produced  by  adenomatous  glands  are  identical  with 
the  phenomena  of  overactivation  of  the  kinetic  system  from  other 
causes.  There  is  increased  metabolism;  increased  circulation,  increased 
respiration;  there  is  a  tendency  to  the  production  of  fever.  When  the 
organism  is  rendered  hyperactive  by  an  adenoma,  any  other  activation 
— such  as  emotion,  exertion,  infection,  causes  an  abnormal  response. 
The  activity  of  the  heat  elimination  mechanism  is  increased,  as  is 
indicated  by  the  increased  circulation  in  the  skin  and  the  increased 
activity  of  the  sweat  glands.  The  activity  of  the  brain  is  increased 
and  its  thresholds  are  low.  Energy  is  discharged  with  the  increased 
facility  characteristic  of  the  hyperdynamic  state.  The  entire  kinetic 
system  shows  the  organic  changes  characteristic  of  over^^ork — the 
liver  is  enlarged,  its  cells  are  degenerated;  the  muscular  system  shows 
degeneration;  the  adrenals  are  sometimes  hypertrophied;  there  is  a 
tendency  to  glycosuria;  the  kidneys  show  a  tendency  to  nephritis,  the 
myocardium  may  become  degenerated;  the  brain  cells  are  exhausted. 
The  whole  organism  has  been  impartially  driven  by  the  thyroid  cells 
of  the  adenoma.  The  sjonptoms  are  identical  with  those  produced  by 
overfeeding  with  thyroid  extract  or  by  iodin  or  by  overwork  of  any 
kind.  What  has  caused  this  body-wide  effect?  Conclusive  evidence 
that  it  is  due  to  a  pathologically  altered  secretion  is  wanting. 

Indeed,  it  would  appear  that  the  designation  of  this  abnormal 
thyroid  stimulation  as  thyreotoxicosis  does  not  correctly  express  the 
disease.  It  would  be  as  fitting  to  designate  the  kinetic  phenomena  of  a 
breakdown  from  excessive  athletic  strain  as  ''athletic-toxicosis,"  or 
the  damaging  kinetic  action  of  excessive  emotion  as  "emotio-toxicosis." 

A  possible  clue  to  the  body-wide  action  of  the  active  adenomata 
may  develop  from  the  finding  in  our  laboratory  studies  of  the  electric 
conductivity  of  normal  and  pathological  tissues,  namely,  that  the  con- 
ductivity of  some  of  the  adenomata  measured  was  higher  than  the 
conductivity  of  any  other  tissue  studied. 

MYXEDEMA. 

In  the  preceding  sections  we  have  considered  the  effect  on  the  body 
of  an  increased  activity  of  the  thyroid.  What  are  the  effects  of  dimin- 
ished thyroid  activity?  When  the  thyroid  secretion  is  diminished 
below  the  needs  of  the  organism  we  find  antithetical  phenomena  to 
those  produced  by  the  hyperactive  gland — diminished  muscular  power, 
diminished  mental  power,  diminished  consumption  of  energy-producing 
compounds,  decreased  intake  of  food  energy,  increase  of  stored  energy 
in  the  form  of  fat,  much  swelling  of  subcutaneous  tissue.  The  low  ebb 
of  kinetic  activity  is  evidenced  by  the  low  temperature,  the  mild  reac- 
tion to  infection,  to  trauma,  to  environmental  stimuli  which  in  the 
normal  individual  would  excite  fear  or  anger.  The  individual  becomes 
adynamic,  stupid,  heavy.  There  are  frequently  pains  in  the  joints 
with  some  thickening  of  the  joint  surfaces  and  margins.     All  these 


814  THE  DUCTLESS  GLANDS 

phenomena  are  as  obviously  phenomena  of  diminished  oxidation  as 
those  of  hypersecretion  are  phenomena  of  increased  oxidation. 

These  phenomena  are  pecuhar  to  the  developed  adult  with  dimin- 
ished thyroid  activity. 

There  is  also  a  congenital  thyroid  deficiency — cretinism — which 
occurs  chiefly  in  goiterous  districts.  The  cretin  develops  slowly,  both 
mentally  and  physically,  and  at  twenty  may  be  no  more  mature  than 
a  child  of  eight.  Not  only  is  there  lack  of  physical  and  mental  develop- 
ment, but  sex  differentiation  does  not  occur — the  cretin  is  in  effect 
a  neuter. 

If  thyroid  feeding  be  initiated  at  an  early  date,  the  cretin  may  be 
transformed  into  a  normal  individual.  Bodily  growth  will  be  promoted, 
mental  development  awakened,  the  secondary  sexual  characteristics 
will  be  established,  and  as  a  final  proof  of  the  efficiency  of  the  normal 
production  of  the  thyroid  gland,  the  congenital  cretin  may  be  so  trans- 
formed by  the  administration  of  thyroid  extract  as  to  become  fertile. 

EXOPHTHALMIC  GOITER— GRAVES'S  DISEASE. 

With  two  exceptions  the  phenomena  of  exophthalmic  goiter — 
Graves's  disease — are  identical  with  those  which  accompany  acti- 
vation of  the  kinetic  system  by  any  other  cause,  whether  fear,  anger, 
sexual  excitation,  athletic  contests,  acute  overwork,  acute  infection, 
or  the  presence  of  an  adenoma.  The  two  exceptions  are  the  invariable 
presence  of  thyroid  enlargement  in  Graves's  disease,  and  the  fact  that 
in  Graves's  disease  the  activation  is  continuous  and  is  not  interrupted 
by  sleep,  which  is  true  of  infection  also.  Even  the  pathology  of 
Graves's  disease  is  characteristic  of  each  of  the  other  forms  of  kinetic 
activation.  ]\Ioreover  with  but  two  exceptions  the  phenomena  of 
Graves's  disease  are  identical  with  those  of  hyperactivation  from 
adenomata,  the  exceptions  being  the  presence  in  Graves's  disease  of 
thyroid  hyperplasia,  and  of  the  emotional  facies  with  exophthalmos. 

Another  distinction  may  be  added:  In  exophthalmic  goiter  the 
pathologic  activation  may  be  broken  at  any  of  the  links  in  the  kinetic 
chain;  the  drive  of  the  hj'perkinetic  adenoma  can  be  controlled  only 
by  the  removal  of  the  adenoma. 

The  identity  of  the  phenomena  of  kinetic  activation  with  exoph- 
thalmic goiter  is  especially  exemplified  by  the  difficulty  in  differen- 
tiating between  exophthalmic  goiter  and  the  infections.  Clinicians 
of  wide  experience  at  times  mistake  latent  tuberculosis  for  Graves's 
disease,  and  Graves's  disease  for  latent  tuberculosis.  The  author 
recalls  that  in  one  instance  one  of  the  best  diagnosticians  he  has  ever 
known  mistook  an  advanced  case  of  Graves's  disease  for  chronic 
tuberculous  meningitis.  Tachycardia,  increased  respiration,  flushed 
face,  tremors,  slight  fever,  no  cough,  nervousness,  anxious  facies,  rapid 
loss  of  weight  are  alike  signs  of  tuberculosis  and  of  Graves's  disease 
in  the  stages  before  the  distinguishing  physical  signs  of  either  are 
marked. 


EXOPHTHALMIC  GOITER— GRAVES'S  DISEASE  815 

Differentiation  between  Exophthalmic  Goiter  and  Thyreotoxicosis. — - 

As  noted  above,  the  hyperplastic  gland  in  Graves's  disease  is  asso- 
ciated with  exophthalmos  and  emotional  facies.  Adenoma  toxemia 
shows  neither  of  these  phenomena.  There  is  a  distinct  difference  in 
the  clinical  symptoms  also — Graves's  disease  rims  a  far  more  irregular, 
more  dynamic  course.  In  Graves's  disease  the  thyroid  output  is 
largely  under  the  control  of  the  nervous  system,  and  in  consequence 
it  is  largely  governed  by  environmental  stimuli.  Environment  in- 
fluences the  output  from  the  adenomatous  gland  but  slightly  if  at  all. 

The  adenoma  toxicosis  therefore  runs  a  chronic,  more  even  course  as 
compared  with  the  acute  uneven  course  of  Graves's  disease.  Excision 
of  the  adenomatous  gland  is  safer  than  of  the  hyperplastic  type;  and 
the  clinical  end-results  of  the  former  are  better,  probably  because  of 
the  lack  of  nervous  involvement.  Ligation  of  the  superior  thyroid 
arteries  exeHs  less  influence  on  cases  of  adenoma-thyreotoxicosis  than 
on  cases  of  exophthalmic  goiter.  This  difference  may  well  be  due  to 
the  fact  that  the  cases  of  pure  Graves's  disease  are  more  completely 
under  the  influence  of  the  nerve  supply  of  the  thyroid.  In  ligation 
the  nerve  supply  is  broken. 

The  Mechanism  of  Exophthalmic  Goiter. — lodin  increases  the  electric 
conductance  of  living  tissue;  iodin  increases  permeability;  increase 
in  permeability  increases  function.  It  is  apparent  that  the  thyroid 
gives  off  its  iodized  protein  adaptively  in  exertion,  in  emotion,  in 
infection,  in  procreation,  etc. 

Ashoff  and  others  state  that  stimulation  of  the  nerve  supply  of  the 
thyroid  causes  a  discharge  of  iodin;  hence,  we  may  suppose  that  the 
output  of  iodin  is  in  part  at  least  under  the  control  of  the  nervous  sys- 
tem. In  exophthalmic  goiter,  there  is  marked  nervous  activity  and 
we  may  suppose  that  the  thyroid  is  under  active  stimulation;  that  this 
is  the  case  is  shown  by  the  low  iodin  content  of  the  gland  in  exoph- 
thalmic goiter.  Cannon  states  that  adrenalin  activates  the  thyroid. 
We  assume  that  the  activated  thyroid  throws  out  large  amounts  of 
activating  iodin  which  by  so  much  facilitates  permeability;  hence, 
increases  activity  of  the  body,  including  the  activity  of  the  thyroid 
itself  and  of  the  adrenals.  Oxidation  is  the  basic  process  in  metab- 
olism; adrenalin  increases  oxidation;  iodin  increases  electric  conduc- 
tance, hence  increases  metabolism. 

Therefore,  through  the  mediation  of  the  nervous  system,  a  reciprocal 
interaction  is  established  among  the  thyroid,  the  adrenals  and  the 
nervous  system.  Iodin  alone,  adrenalin  alone,  thyroid  extract  alone, 
emotion,  or  exertion,  or  infection  alone,  each  causes  a  "Kinetic  Drive" 
with  phenomena  similar  to  those  of  exophthalmic  goiter. 

If  the  foregoing  interpretation  be  correct,  then  the  drive  of  exoph- 
thalmic goiter  should  be  diminished  by  lessening  the  activity  of  any 
one  of  the  three  interacting  organs — of  the  brain,  by  rest  cure;  of 
the  thyroid,  by  its  resection;  of  the  adrenals,  by  the  removal  of  a 
portion  of  its  tissue,  though  evidence  of  the  positive  value  of  the 
last-named  procedure  is  thus  far  incomplete. 


816  THE  DUCTLESS  GLANDS 

Nothing  in  surgery  is  more  striking  than  the  immediate  benefit  of 
surgical  treatment  of  exophthalmic  goiter,  as  evidenced  by  the  results 
of  2180  partial  thyroidectomies  performed  by  the  author,  of  which 
1148  were  for  exophthalmic  goiter. 

It  is  of  interest  to  note  that  the  active  principle  of  thyroid  secretion 
has  been  synthetically  produced  by  Kendall;  adrenalin  is  syntheti- 
cally made;  and  electricity  is  everywhere  fabricated;  hence,  the 
equivalents  of  the  activators  of  exophthalmic  goiter,  of  emotion,  of 
exertion,  and  of  fever  may  be  made  in  the  laboratory. 

Among  the  results  often  noted  after  thyroidectomy  are: 

(a)  A  decrease  in  the  systolic  pressure  and  less  frequently  a  decrease 
in  the  diastolic  pressure. 

(6)  Diminished  nervousness. 

(c)  Diminished  myocarditis. 

(d)  General  restoration  of  the  widespread  impairment  due  to  the 
excessive  speeding  of  the  kinetic  system. 

In  a  case  thus  relieved,  an  overdose  of  thyroid  extract  will  reestab- 
lish the  sxTnptoms.  The  postoperative  state  of  serenity  of  the  exoph- 
thalmic goiter  patient  is  comparable  to  the  colorless  state  after  one  has 
passed  through  a  great  emotion. 

The  Mechanism  of  the  Infections  in  their  Relation  to  the  Thyroid  Gland. 
— That  the  thyroid  is  involved  in  the  response  to  infection  is  shown 
by  the  following  facts: 

In  cases  of  excessive  thyroid  feeding  and  of  exophthalmic  goiter 
there  is  an  increased  metabolism,  and  infections  cause  abnormally 
high  temperatures. 

In  myxedema  the  body  temperature  is  subnormal,  and  though 
myxedematous  subjects  succumb  to  infections,  they  show  little 
febrile  reaction. 

As  stated  above  the  specific  action  of  the  thyroid  is  due  to  its  special- 
ized iodin.  There  is  strong  evidence  that  the  brain  drives  the  organism 
by  means  of  electric  energy.  Iodin  causes  an  increase  in  electric 
conductance,  therefore  the  effective  work  of  the  electric  energy  theo- 
retically created  by  the  cells  of  the  nervous  system  would  be  corre- 
spondingly increased  by  the  iodin  facilitation. 

Iodin  alone  causes  all  the  sjinptoms  of  an  infection.  It  is  almost 
impossible  to  differentiate  between  an  acute  infection  and  acute 
iodoform  poisoning. 

After  operations  for  exophthalmic  goiter,  who  can  distinguish 
with  accuracy  between  the  febrile  reaction  facilitated  by  the  activation 
of  the  organism  by  the  hyperactive  thyroid  and  the  activation  due  to 
an  acute  infection? 

In  chronic  infections,  and  even  in  prolonged  acute  infections  such  as 
tuberculosis,  the  thyroid  is  hyperplastic.  Thyroid  enlargement,  is 
frequently  demonstrable  during  an  acute  infection.  Acute  tonsillitis 
may  cause  the  thyroid  to  enlarge  and  to  remain  enlarged. 
>  After  the  removal  of  infected  tonsils  the  thyroid  sometimes  subsides 
promptly. 


EXOPHTHALMIC  GOITER— GRAVES'S  DISEASE  817 

In  the  acute  infections,  even  in  the  chronic  infections,  the  indi- 
vidual is  palpably  under  the  influence  of  the  thyroid.  One  of  the 
evidences  of  this  is  the  nervous  state  of  the  patient,  which  is  but  an 
indication  that  the  nerve  pathways  have  been  facilitated  by  iodin  for 
the  more  ready  passage  of  the  electric  driving  force. 

All  the  experimental  and  clinical  evidence  indicates  that  a  large 
role  is  played  by  the  thyroid  in  the  defense  of  the  organism  against 
the  infections. 

The  Mechanism  of  Nervousness  in  the  Infections  in  its  Relation  to  the 
Thyroid  Gland. — The  evidence  of  the  participation  of  the  thyroid  may 
with  equal  logic  be  applied  to  the  obvious  mechanism  of  nervousness. 

In  exophthalmic  goiter  cases  the  nervousness  is  similar  to  that  of 
infections — the  restlessness,  the  tossing  and  the  sleeplessness  may  be 
regarded  as  phenomena  of  the  facilitation  of  the  electric  conductance 
by  iodin. 

On  the  next  day  after  a  lobectomy  has  been  performed  in  an 
exquisitely  nervous,  excitable,  exophthalmic  goiter  patient,  the  one 
conspicuous  change — conspicuous  to  the  nurse,  but  of  infinite  comfort 
to  the  patient — is  the  loss  of  the  Intolerable  restlessness,  intolerable 
excitability.  We  may  conclude,  therefore,  that  the  nervousness  in 
fever  is  due  to  the  increased  action  of  the  thyroid.  Do  myxedema 
patients  show  an  equal  increase  of  nervousness  in  infections? 

The  Treatment  of  Exophthalmic  Goiter. — In  advanced  exophthalmic 
goiter  the  internal  respiration  is  abnormally  sensitive,  as  indicated  by 
the  adrenalin  test  (Goetsch),  by  the  baneful  effect  of  diminished 
exchange  of  air  from  obstruction  to  the  trachea,  or  from  any  interfer- 
ence with  the  internal  respiration,  as  in  deep  anesthesia,  and  by  the  ill 
effect  of  increased  internal  respiration  from  emotion  or  from  injury. 
The  operative  procedure  therefore  should  be  graded  according  to  the 
severity  of  the  disease. 

The  anesthetic  should  be  nitrous  oxide,  which,  as  a  rule,  should 
be  administered  in  bed,  the  patient  being  transferred  to  the  operating 
room  after  anesthesia  is  established. 

In  moderate  cases  the  entire  operation  may  be  completed  in  one 
seance.  In  more  severe  cases  the  thyroid  activity  should  be  dim- 
inished by  a  preliminary  ligation  in  bed,  under  nitrous  oxide  analgesia 
and  local  anesthesia. 

In  extremely  grave  cases  it  may  be  necessary  to  diminish  the  thyroid 
activity  by  multiple  steps,  ligation  of  one  vessel,  ligation  of  the  second 
vessel,  partial  lobectomy,  complete  lobectomy,  allowing  intervals  of 
a  month  or  more  between  these  successive  stages.  If  during  operation 
the  pulse  runs  up  beyond  the  safety-point,  it  is  advisable  to  stop  the 
operation  and  dress  the  wound  with  flavin,  completing  the  operation 
after  a  day  or  two  when  conditions  are  safe.  In  some  cases,  though 
the  thyroid  is  resected,  it  is  advisable  to  dress  the  unsutured  wound 
with  flavin  and  make  a  delayed  closure  in  bed  the  following  day  under 
analgesia.  In  certain  cases  lobectomy  is  performed  in  bed  under 
nitrous  oxide  analgesia  and  local  anesthesia. 

VOL.  I — 52 


818  THE  DUCTLESS  GLANDS 

In  multiple  stage  operations  the  length  of  the  interoperative  inter- 
vals is  determined  by  the  degree  of  physiological  adjustment. 

Psychic  control  is  required  throughout  to  diminish  the  intense 
drive  by  establishing  confidence  and  hope.  An  anociated  regimen  should 
be  prescribed  for  the  preoperative,  interoperative  and  postoperative 
periods. 

If  after  operation  there  is  inaugurated  an  excessively  high  tempera- 
ture, with  greatly  increased  pulse  and  respiration,  then  on  the  prin- 
ciple that  heat  increases  chemical  activity  and  electric  conductivity, 
and  that  these  in  turn  increase  heat — such  patients  are  literally 
packed  in  ice — packed  early.  This  procedure  has  been  found  to  exer- 
cise a  remarkable  control  over  the  destroying  metabolism. 

This  postoperative  phase  of  exophthalmic  goiter  is  closely  analogous 
to  heatstroke  in  s\Tnptoms  and  in  control;  and  both  heatstroke  and 
the  so-called  postoperative  hyperthyroidism  are  the  antithesis  of 
shock  in  which  by  contrast  the  mechanism  for  the  fabrication  of  heat 
is  paralyzed.  In  the  latter,  heat  is  as  useful  as  cold  is  in  the  former. 
The  treatment  for  each  is  planned  in  accordance  with  the  simple  laws 
of  physics.  The  practicability  of  the  plan  of  treatment  outlined  above 
has  made  possible  in  the  Lakeside  Clinic  the  following  record:  206 
consecutive  thyroidectomies,  of  which  72  were  of  the  exophthalmic 
type  without  a  death;  100  ligations  without  a  death.  No  case  is 
rejected  for  operation. 


THE  ADRENALS. 

In  the  preceding  sections  we  have  referred  to  the  interaction  of  the 
thyroid  with  other  component  parts  of  the  kinetic  system,  particularly 
the  adrenals.  In  addition  to  this  interaction  between  the  thyroid  and 
the  adrenals  the  effects  of  the  secretion  of  the  glands  are  identical,  for 
adrenalin  alone,  as  Cannon  has  shown,  like  thyroid  secretion,  causes 
all  the  basic  phenomena  of  exertion,  of  emotion,  of  infection,  of  auto- 
intoxication, etc. 

The  interaction  of  these  glands  and  their  specific  function  in  the 
kinetic  system  may  be  briefly  expressed  as  follows :  The  thyroid  gland 
has  been  evolved  to  hoard  iodin  (Marine).  lodin  facilitates  oxidation 
— metabolism.  Oxidation  is  markedly  controlled  by  adrenalin.  In 
their  capacity  to  promote  metabolism  upon  which  vital  processes 
depend  the  adrenals  and  the  thyroid  may  be  considered  the  activators 
of  the  kinetic  system.  Although  the  action  and  the  end-effects  of  the 
secretion  of  the  adrenals  and  of  the  thyroid  are  identical  in  many 
respects,  an  important  distinction  in  the  action  of  these  organs  should 
be  noted.  The  action  of  adrenalin  is  immediate  and  evanescent;  the 
action  of  thyroid  secretion  is  slower,  but  is  persistent.  It  is  the  long 
pull,  therefore,  the  protracted  worry,  the  chronic  infection,  the  pro- 
longed activations  of  adolescence  and  of  pregnancy  that  tax  the 
thyroid.    For  the  sudden  discharge  of  energy  in  sudden  anger,  in  a 


THE  ADRENALS  819 

short  intense  struggle,  in  an  acute  infection  of  sudden  onset,  in  an 
overwhelming  emotional  crisis,  the  adrenals  supply  the  material  to 
meet  the  unexpected  demand  for  increased  metabolism. 

When  there  is  adrenal  deficiency  the  power  of  the  body  to  fabricate 
heat  and  muscular  or  mental  action  is  diminished  or  lost. 

Electric  Conductivity  in  its  Relation  to  the  Adrenals  and  the  Thyroid. — 
A  further  clue  to  the  function  of  the  adrenals  and  of  the  thyroid  as 
activators  has  been  found  in  a  line  of  research  now  in  progress  in  our 
laboratory  in  which  the  electric  conductivity  of  animal  tissues  has 
been  studied  under  varying  conditions,  in  particular  those  conditions 
whose  phenomena,  as  we  have  stated  above,  are  identical  with  those 
that  follow  the  administration  of  adrenalin  and  of  thyroid  secretion, 
i.  e.,  intense  short  seances  of  exertion  and  of  emotion,  protracted 
seances  of  exertion  and  of  emotion,  the  immediate  and  the  late  effects 
of  physical  injury  (surgical  shock),  early  and  late  infection,  iodoform 
poisoning,  pregnancy,  etc.  We  found  that  sudden  crises,  such  as  a 
short  intense  seance  of  fright,  the  immediate  reaction  to  an  acute 
infection,  physical  injury,  the  injection  of  adrenalin  caused  an  immedi- 
ate increased  conductivity  of  the  brain,  followed  by  a  late  decrease. 

It  is  through  the  brain  that  the  environmental  stimulus  is  conveyed 
to  the  adrenals  and  to  the  thyroid.  If  activation  of  the  brain  and 
the  response  of  the  organism  is  a  phenomenon  of  electric  energy, 
as  accumulating  evidence  leads  us  to  believe,  then  since  electric  energy 
depends  upon  oxidation,  and  oxidation  is  influenced  by  adrenalin  and 
by  thyroid  secretion,  the  role  of  the  thyroid  and  of  the  adrenals  as 
activators  of  the  electrically  operated  mechanisms  is  further  established. 

It  is  not  without  interest  to  note,  and  perhaps  it  is  significant,  that 
convulsions  frequently  occur  in  the  onset  of  acute  infectious  diseases 
in  children,  in  which  there  is  reason  to  believe  there  is  a  free  output 
of  adrenalin,  a  quick  and  powerful  metabolic  activation.  This  increased 
metabolic  activity  may  be  interpreted  to  mean  an  increased  output  of 
electricity,  so  great  that  the  overdriven  motor  cortex  in  turn  drives 
the  organism  to  extensive  muscular  contractions — convulsions. 

Moreover,  if  electricity  is  the  driving  force  of  the  organism,  and 
if  electric  power  is  increased  by  increasing  the  conductance  of  the 
tissues  over  which  it  passes,  it  would  follow  that  there  must  be  in  the 
body  an  organ  which  can  supply  to  the  body  a  substance  which  can 
immediately  increase  electric  conductance  to  meet  sudden  crises, 
and  an  organ  which  for  periods  of  weeks  and  months  can  furnish  a 
continuous  supply  of  a  substance  which  can  accomplish  the  same 
purpose  for  protracted  needs. 

Adrenalin,  as  our  conductivity  studies  would  indicate,  answers  the 
first  requirement.  As  to  the  second,  Osterhout  has  shown  that  iodin 
increases  electric  conductivity  in  living  tissues,  and  our  studies,  referred 
to  above,  of  the  effects  upon  electric  conductivity  of  thyroid  feeding 
and  of  iodoform  poisoning  indicate  that  the  protracted  needs  of  the 
electrochemical  mechanism  may  be  well  met  by  the  thyreo-iodin 
fabricated  by  the  thyroid. 


SUEGEEY  OF  THE  THYMUS  GLAND. 

By  a.  J.  OCHSNER,  M.D. 

There  is  no  other  important  organ  in  the  human  body  which  has 
received  so  little  surgical  attention  as  the  thymus  gland. 

1.  The  gland  is  inaccessible  as  compared  to  other  structures,  but 
this  is  a  more  apparent  than  real  reason  for  the  fact  that  surgeons  have 
avoided  interfering  with  this  gland;  because  its  removal  is  really  quite 
simple,  and  except  for  the  fact  that  patients  in  whom  the  operation  is 
indicated  are  bad  risks  from  their  long-continued  suffering,  the  oper- 
ation would  be  relatively  quite  safe  if  performed  according  to  the  rules 
laid  down  by  Kocher,  Olivier,  Crotti  and  Mayo. 

2.  The  most  important  reason  lies  in  the  fact  that  practically  the 
entire  physiological  existence  of  the  thymus  gland  is  confined  to  a 
period  of  the  life  of  patients  when  they  became  the  objects  of  surgical 
treatment  only  in  case  of  serious  acute  disease,  such  as  empyema, 
appendicitis  and  only  conditions  due  to  infection  or  trauma. 


Trachea 
Thyroid  veins 

Right  vagus 

Superior  vena  caia 


Thyroid  body. 

left  common  carotid  artery. 
Left  internal  jugidar  vein. 

Left  subclavian  vessels. 


Fig.  562. — The  thymus  gland  of  a  full-tmie  letus  exposed  m  situ.     (Gray.) 


3.  This  gland  from  the  time  of  the  birth  of  the  child  has  a  tendency 
to  eliminate  itself  from  the  organism,  and  consequently  becomes 
rapidly  less  important  as  the  patient  becomes  more  and  more  important 
surgically.  Its  growth  ceases  under  normal  conditions  about  at  the 
end  of  the  twelfth  year  of  age.  Soon  after  this  it  begins  to  decrease, 
so  that  at  the  age  of  eighteen  to  twenty  it  is  little  more  than  a  rudiment- 
ary remnant.  At  birth  the  gland,  according  to  Hammar,  should  weigh 
about  13.26  grams;  at  its  greatest  development  between  the  age  of 

(821) 


822  SURGERY  OF   THE   THYMUS  GLAND 

eleven  and  fifteen  years,  37.52  grams,  or  nearly  three  times  the  original 
weight;  and  at  seventy-five  years  of  age,  only  about  one-half  the  weight 
at  birth,  or  6  grams. 

4.  The  only  surgical  treatment  which  seems  available  consists  in  the 
removal  of  the  gland,  which  seems  a  formidable  operation  for  condi- 
tions which  are  supposed  to  be  caused,  entirely  or  partly,  by  abnormal 
action  of  the  thymus  gland. 

5.  It  is,  however,  likely  that  a  very  important  reason  for  the  absence 
of  th>Tnus-gland  surgery  lies  in  the  fact  that  our  attention  has  not  been 
directed  to  this  organ,  and,  like  many  other  organs  Avhich  were  over- 
looked surgically  until  recent  years,  careful  observation  and  study  and 
attention  to  this  organ  may  uncover  pathological  conditions  which 
will  in  the  future  class  these  in  the  list  of  surgical  diseases  for  a  time 
at  least. 

6.  At  the  present  time  the  condition  which  seems  to  attract  most 
attention  is  hypertrophy  of  this  gland  in  children,  resulting  in  pressure 
upon  the  trachea,  and  persistence  of  the  gland  in  adults  at  a  time  when 
the  organ  should  have  been  eliminated  by  the  natural  course  of  trophic 
events  in  the  development  of  the  human  body.  In  both  instances  the 
systematic  application  of  properly  regulated  .r-ray  seems  to  suffice, 
in  most  cases,  to  relieve  the  condition  safely  and  for  promptly  doing 
away  with  the  necessity  of  surgical  interference. 

What  has  been  accomplished  surgically  has  been  confined  to  the  work 
of  relatively  few  surgeons,  whose  activity  in  the  surgery  of  the  thyroid 
gland  has  attracted  their  attention  especially  to  this  organ,  which  is 
closely  related  to  the  former. 

The  position  of  the  thymus  gland  places  it  in  relation  to  so  many 
important  structures  that  a  timid  surgeon  would  scarcely  feel  inclined 
to  attempt  its  removal. 

It  lies  between  the  sternum  and  the  trachea  above  and  approaches 
the  pericardium  and  large  vessels  below.  Laterally  lie  the  large 
vessels  of  the  neck,  the  phrenic  nerves  and  on  the  left  side  the  gland 
touches  the  pneumogastric  and  the  recurrent  laryngeal  nerves. 

Obstruction  to  inspiration,  due  to  pressure  of  the  thymus  gland  upon 
the  trachea,  is  characterized  by  cyanosis  during  inspiration  and  retrac- 
tion of  the  contour  of  the  neck,  while  during  expiration  there  may  be  a 
bulging  in  this  region. 

The  first  thjTnectomy  was  performed  by  von  Rehn  in  Frankfort  in 
1896,  giving  perfect  relief  in  a  case  of  obstruction  to  respiration,  due  to 
pressure  caused  by  an  enlarged  thymus  gland. 

There  seems  to  be  an  intimate  relation  between  the  thymus  gland  and 
the  various  organs  of  internal  secretion,  which  has  been  borne  out  both 
oy  animal  experimentation  and  clinical  observation;  but  at  the  present 
time  this  relation  has  not  as  yet  been  definitely  analyzed.  It  seems 
certain,  however,  that  the  most  important  function  of  this  organ  has 
to  do  with  the  trophic  element  in  the  development  of  the  human  body, 
and  that  when  the  adult  growth  has  been  reached  the  organ  withdraws 
physiologically  from  its  active  participation  in  the  influence  upon  any 


DIAGNOSIS  823 

of  the  organs  of  the  body  except  in  so  far  as  it  seems  to  supplement 
some  of  the  functions  of  the  thyroid  gland,  probably  to  a  slight  degree. 

The  interrelation  between  the  thyroid  gland  and  the  thymus  seems 
to  be  confirmed  by  the  fact  that  the  tissues  of  the  thymus  gland  become 
more  active,  as  is  shown  by  histological  changes  when  the  thyroid  gland 
has  been  removed. 

In  goiter  regions  the  newborn  have  an  enlargement  of  the  thymus 
gland  in  a  large  proportion  of  the  cases  examined  at  postmortem,  al- 
though in  only  a  small  number  of  infants  born  with  hyperplasia  of  the 
thymus  is  there  any  marked  hypertrophy  of  the  thyroid  gland  at  the 
time  of  birth.  On  the  other  hand,  in  these  regions  the  combination  of 
goiter  and  hyperplasia  of  the  thymus  gland  is  very  common  in  the 
adult. 

Diagnosis. — There  are  two  conditions  which  are  most  likely  to  cause 
the  diagnostician  to  suspect  hypertrophy  of  the  thjTnus  gland — namely, 
obstruction  to  respiration,  which  cannot  be  accounted  for  in  any  other 
way,  and  a  condition  characterized  by  general  hyperplasia  of  the  entire 
lymphatic  system,  tonsils  and  adenoids,  and  enlargement  of  the  spleen, 
with  a  pale,  sallow  color  of  the  patient  and  a  lack  of  energy  and  resist- 
ance, a  condition,  called  by  Paltauf  "status  lymphaticus. "  This 
condition  is  most  common  in  infancy. 

J.  F.  Herrick^  gives  obstruction  as  one  of  the  chief  symptoms  of  hyper- 
trophy of  the  thymus  in  infancy;  the  left  lobe  often  being  larger,  causes 
greater  pressure.-  The  symptoms  often  simulate  foreign  bodies  in  the 
trachea. 

He  attributes  some  deaths  to  pressure  upon  the  pneumogastric 
nerve,  the  great  vessels  and  the  auricle,  counting  this  more  important 
in  many  cases  than  pressure  upon  the  trachea.  Percussion  and  n-ray 
examination  give  the  most  positive  indication  of  the  size  of  the  enlarged 
gland. 

E.  Olivier,^  who  prefers  surgical  treatment  to  .T-ray,  classifies  thymus 
hypertrophy  in  three  forms:  (1)  Continuous  form  with  permanent 
dyspnea.  (2)  Intermittent  form  with  suffocation  crises.  (3)  Atypical 
form. 

He  classifies  the  symptoms  as  follows  for  Class  I : 

(a)  Bad  respiration  from  early  age.  Beginning  of  respiration  easy; 
last  half,  difficult,  the  air  having  to  be  pushed  out.  Respiration  worse 
at  night. 

(6)  Permanent  dyspnea. 

(c)  Rales  and  stridor  on  inspiration. 

(d)  Substernal  median  retraction  increased  by  hyperextension  of 
head  and  recumbent  position. 

(e)  On  expiration  thymus  appears  in  neck,  disappears  on  inspiration 
behind  manubrium. 

(/)  There  may  be  bulging  of  sternum  with  dulness  of  percussion. 

1  Svirg.  Gynec.  and  Obst. 

2  De  la  valeur  et  des  indications  operatoire  du  thymus,  Veau  et  Olivier,  Jour,  de  Chir., 
1912,  p.  233. 


824  SURGERY  OF  THE  THYMUS  GLAND 

He  points  out  the  importance  of  differentiating  enlarged  tracheo- 
bronchial glands  following  bronchopneumonia.  The  thymic  tumor  is 
less  voluminous  and  less  lobulated  than  glands.  In  this  the  a:-ray  and 
the  previous  history  are  most  important.  He  gives  as  indications  for 
operation  the  following  three  conditions:  permanent  dyspnea,  stridor, 
suffocation.    His  statistics  show  twenty  operations  with  eight  deaths. 

The  non-surgical  treatment  consists  in  the  careful  use  of  .r-ray  treat- 
ment. J.  F.  Herrick  reports  several  cases  with  ideal  results  in  children. 
The  method  of  treatment  corresponds  with  that  described  in  the 
chapter  deahng  with  the  therapeutic  use  of  .r-ray  in  this  work. 

It  seems  necessary,  however,  to  regulate  this  treatment  carefully 
according  to  Klose  and  Vogt.^  These  authors  warn  against  the  careless 
use  of  .r-ray  in  these  cases,  because  of  the  danger  of  destroying  the 
entire  gland,  causing  the  production  of  rickets,  retarded  growth  of 
the  child,  anemia,  calcium  elimination,  etc. 

Thymectomy. — ^Two  facts  must  be  borne  in  mind  at  all  times  during 
the  progress  of  this  operation:  (1)  the  fact  that  the  capsule  of  the  gland 
is  quite  closely  in  contact  with  the  large  vessels  mentioned  above;  (2) 
that  in  most  instances  a  line  of  cleavage  can  be  determined  between 
the  capsule  of  the  gland  and  the  surrounding  tissues,  or  in  cases  of 
strong  adhesions,  the  capsule  can  be  left  in  place,  the  surgeon  removing 
only  the  gland  substance,  which  can  usually  be  readily  accomplished, 
especially  if  the  operator's  fingers  are  not  covered  with  gloves.  In  case 
of  injury  to  the  wall  of  one  of  the  veins  the  opening  must  be  instantly 
closed  with  the  end  of  the  finger  to  prevent  air  embolism.  The  cavity 
of  the  capsule  should  then  be  carefully  tamponed  with  gauze,  as  it  is 
difficult  to  control  hemorrhage  because  of  the  danger  of  injuring  impor- 
tant structures.  In  most  cases,  however,  the  bleeding  is  very  slight 
because  at  each  step  of  the  operation  the  tissues  containing  blood- 
vessels are  carefully  clamped,  cut  and  hgated  as  the  operation  pro- 
gresses, so  that  the  wound  can  usually  be  closed. 

The  gland  can  be  approached  most  conveniently  through  the  trans- 
verse collar  incision,  which  has  been  described  frequently  in  connection 
with  the  operation  of  thyroidectomy.  In  fact  the  operation  has  been 
performed  more  frequently  as  an  additional  step  at  the  conclusion  of 
a  thyroidectomy  than  under  any  other  circumstances,  because  it  is 
claimed  by  a  number  of  authorities,  notably  von  Rehn,  Crotti  and 
Kocher,  that  in  the  condition  known  as  status  lymphaticus  compli- 
cating Graves's  disease  the  patient  is  much  more  likely  to  recover  if 
this  step  is  added  to  the  thyroidectomy,  so  that  in  this  class  of  cases, 
which  has  been  looked  upon  as  almost  hopeless,  quite  a  large  proportion 
can  be  operated  successfully  if  thymectomy  is  added  to  thyroidectomy. 

Technic  of  Operation. — In  case  thymectomy  is  to  be  performed  at 
the  conclusion  of  thyroidectomy  the  transverse  collar  incision,  which 
has  been  made  for  the  removal  of  the  thyroid  gland,  furnishes  an  ideal 
approach  to  the  thymus  gland. 

1  Biologie  der  Thymus  Druese,  Tubingen,  1910. 


TECH  NIC  OF  OPERATION  825 

In  case  thymectomy  is  made  as  an  independent  operation  the  same 
incision  should  be  made.  The  anterior  muscles  of  the  neck,  sterno- 
thyroid, sternohyoid  and  sternocleidomastoid  should  be  separated  in 
the  median  line  just  at  the  upper  end  of  the  manubrium  and  carefully 
retracted;  then  the  fascia  extending  from  the  thyroid  to  the  thymus 
gland  should  be  cut  transversely  when  the  upper  end  of  the  enlarged 
thymus  gland  will  be  seen  bulging  upward  into  view. 

This  is  then  seized  with  forceps  and  gently  pulled  upward  out  of  the 
chest  in  case  the  gland  is  not  strongly  adherent.  The  blood  supply 
must  now  be  borne  in  mind  as  coming  from  the  inferior  thyroid,  internal 
mammary  and  sometimes  directly  from  the  subclavian,  hence  the  neces- 
sity of  clamping  these  branches  successively  as  they  are  brought  up 
with  the  gland. 

It  is  best  to  apply  two  pairs  of  forceps  to  each  portion  of  tissue 
grasped  to  cut  between  these  and  to  ligate  carefully  at  once. 

At  the  lower  end  there  are  usually  small  vessels  from  a  cardiophrenic 
branch,  which  must  be  disposed  of  in  the  same  manner.  In  this  way 
the  cavity  can  be  left  practically  dry  and  the  pressure  from  the  sur- 
rounding tissues  will  cause  the  cavity  to  collapse  immediately,  making 
a  closure  of  the  wound  the  ideal  plan. 

In  case  the  capsule  of  the  gland  is  so  strongly  attached  to  the  sur- 
rounding tissues  as  to  make  it  appear  unsafe  to  remove  the  capsule 
together  with  the  gland,  then  the  steps  of  the  operation  are  varied  in 
the  following  manner:  The  gland  is  drawn  up  as  described  above,  but 
the  capsule  is  split  transversely  and  a  finger  is  inserted  between  the 
parenchyma  of  the  gland  and  the  capsule  and  the  former  is  enucleated 
with  great  care  and  gentleness.  When  a  point  of  resistance  is  reached 
the  gland  is  retracted  to  one  side  and  two  pairs  of  hemostatic  forceps 
are  applied  to  the  point.  The  tissue  grasped  is  cut  and  ligated  doubly 
and  the  process  is  continued  until  the  entire  gland  has  been  peeled  out 
of  its  capsule. 

The  oozing  is  stopped  by  means  of  gauze  tampons,  which  are  left 
in  place  five  minutes  or  longer,  when  the  oozing  will  have  stopped,  and 
it  will  be  safe  to  remove  the  tampon  and  permit  the  capsule  to  collapse 
as  before. 

In  case  a  vein  has  been  torn,  which  has  not  been  clamped  and  ligated, 
it  may  become  necessary  to  leave  the  tampon  in  place  for  two  days  and 
to  permit  its  end  to  protrude  from  a  small  incision  below  the  external 
incision,  which  should  be  sutured  throughout. 

This  plan  should,  however,  be  followed  only  in  case  of  absolute 
necessity,  as  most  operators  agree  with  Olivier  in  believing  that  the 
greatest  danger  comes  from  infection,  and  that  this  cannot  be  readily 
avoided  in  case  any  form  of  drainage  or  tampon  is  employed;  for  the 
same  reason  tracheotomy  should  not  be  performed  in  connection  with 
this  operation. 

Anesthesia.  —  The  same  method  of  anesthesia  which  has  been 
described  in  connection  with  the  operation  of  thyroidectomy  is  most 
satisfactory  for  thymectomy. 


INDEX 


Abdominal     distention,     postoperative 
treatment  and,  151 
operations,  shock  in,  surgical  prog- 
nosis and,  49 
Abscess  of  brain,  395 

ataxia  and,  351 
deafness  and,  349 
diagnosis  of,  395 
disorientation  and,  351 
dysmetria  and,  351 
fulminating,  395 
latent,  396 

nystagmus  and,  350,  470 
of  otitic  origin,  469 

after-treatment    of, 

471 
diagnosis  of,  470 
pulse  in,  470 
symptoms  of,  469 
treatment  of,  470 
word  blindness  in,  470 
radiology  in,  356 
stage  of  exacerbation  in,  396 
tinnitus  and,  349 
treatment  of,  397 
vertigo  and,  351,  470 
cold,   of  scalp,   diagnosis  of,   from 

lipoma,  283 
dento-alveolar,  535 
etiology  of,  536 
pathology  of,  536 
streptococcus  viridans  and,  536 
treatment  of,  538 
of  lung,  bronchoscopy  for,  743 
of  neck,  707 

treatment  of,  708 
Acapnia  theory  of  etiology  of  shock,  118 
Acidosis  in  postoperative  treatment,  157 

surgical  prognosis  and,  33 
Acromegaly  of  skull,  311 

diagnosis    of,    from    leontiasis 

ossea,  313 
treatment  of,  313 
tumors  of  hypophysis  and,  341,  343 
Actinomycosis  of  neck,  694 
diagnosis  of,  694 

from  syphiHs,  695 
treatment  of,  695 
of  skull,   diagnosis  of,   from  tuber- 
culosis, 319 
Acute  dilatation  of  stomach,  postopera- 
tive treatment  and,  155 


Adenoma  of  scalp,  281 

of  thyroid  gland,  813 
Adenotome,  530 
Adrenals,  818 

electrical  conductivity  in  its  relation 
to,  819 
Adson's  operation  for  tumors  of  hypoph- 
ysis, 370 
Agglutination  test  in  blood  transfusion, 

194,  195 
Air  embolism,  surgical  prognosis  and,  59 
Alcohol  and  chloroform  as  general  anes- 
thetic, 96 
chloroform    and    ether    as    general 
anesthetic,  96 
Alcoholism,  surgical  prognosis  and,  30 
Ahmentary  tract  in  postoperative  treat- 
ment, 141 
Alveolitis,  chronic,  542 
Alj^in  as  local  anesthetic,  109 
Anemia  complicating  pregnancy,   blood 
transfusion  in,  190 
pernicious,  blood  transfusion  in,  192 
secondary,    blood    transfusion    in, 

190 
surgical  prognosis  and,  36 
Anesthesia,  administration  of,  98 
closed  method,  102 
intrapharyngeal,  100 
intratracheal  insufflation,  99 
intravenous,  100 
Metzer  and  Auer's  method,  99 
open-drop  method,  98 

with  posture,  99 
oral,  102 
rectal,  100 
sequence,  102 
Bier's  intravenous.  111 
in  bronchoscopy,  736 
complications  of,  104 
anuria,  105 
backache,  105 
gas  pains,  105 
nausea,  105 
nephritis,  105 
shock,  106 
vomiting,  105 
in  direct  laryngoscopy,  736 
effects  of,  on  immunity  factors,  sur- 
gical prognosis  and,  42 
on  kidneys,   surgical  prognosis 

and,  41 
on  liver,  surgical  prognosis  and, 
41 

(827) 


828 


INDEX 


Anesthesia,  effects  of  on  lungs,  surgical 
prognosis  and,  42 
on    nervous    sj^stem,    surgical 

prognosis  and,  42 
remote,  surgical  prognosis  and, 
41 
endoneural,  112 

in  exophthabnic  goiter,  795,  797 
infiltration,  117 

in  operations  for  cleft    palate,  612 
parasacral,  115 
paravertebral,  114 
perineural,  112 
postoperative  nausea  and,  42 

vomiting  and,  42 
preparation  of  patient  for,  97 
regional,  111 
spinal,  112 

surgical  prognosis  and,  38 
topical,  ill 
Anesthesin  as  local  anesthetic,  110 
Anesthetic,  choice  of,  103 
Anesthetics,  general,  93 

alcohol  and  chloroform,  96 

chloroform  and  ether  96 
Billroth's  mixture,  96 
chloroform,  94 
ether,  94 

and  chloroform  96 
ethyl  chloride,  95 
nitrous  oxide,  95 
oxygen,  95 

Schleich's  mixture,  96 
local,  106 

action  of,  107 
administration  of.  111 
alypin,  109 
anesthesin,  110 
apothesin,  110 
cocain,  108 
eucain,  109 

morphin  and  atropin,  108 
novocain,  109 
preparation  of,  107 
procain,  109 
quinine  salts,  110 
stovain,  109 
tropacocain,  109 
Anesthetist,  97 

Aneurysmal  varix  of  scalp,  283 
treatment  of,  284 
Aneurysms  of  neck,  690 
diagnosis  of,  690 
treatment  of,  692 
of  scalp  by  anastomosis,  285 
arteriovenous,  283 
circoid,  285 
traumatic,  283 

treatment  of,  283 
Angioma  arteriale  racemosmn  of  scalp, 
285 
diagnosis  of,  286 
treatment  of,  286 
of  neck,  716 
of  scalp,  286 

cavernous,  287 


Angioma  of  scalp,  diagnosis  of,  287 
plexiform,  285 
treatment  of,  287 
Angiosarcoma  of  scalp,  293 
Angle's  splint  for  fractured  lower  jaw, 

626 
Antrum  of  Highmore,  operations  on,  507 
Beck's  obhteration,  511 
after-treatment  in,  512 

technic  of,  511 
sublabial,  510 

after-treatment,  511 
technic  of,  508 
Anuria  complicating  anesthesia,  105 
Apothesin  as  local  anesthetic,  110 
Army  temporarj'  splint  in  fractures  of 

jaw,  629 
Arteries,  ligation  of,     in     treatment     of 

goiter,  784 
Arteriovenous  aneurysm  of  scalp,  283 
Arthritis,  gonorrheal,  vaccines  in,  181 
rheumatic,  vaccines  in,  181 

dosage  in,  182 
suppurative,  vaccines  in,  180 
Aseptic  and  antiseptic  technic,  79 
operation,  technic  of,  83 

after-care  of  instruments, 
88 
of  operating  room,  88 
disinfection  of  catheters,  88 
of  instruments,  88 
of  skin,  86 

of  surgical  dressings,  91 
preparation  of  catgut,  89 
Bartlett's  method, 

90 
chromicized,  89 
unchromicized,  89 
of  gutta-percha,  90 
of  hands,  84 
of  horsehair,  89 
of  operating  room,  88 
of  rubber  tubing,  90 
of  silkworm  gut,  89 
resterilizing  used  dressings, 

92 
use  of  rubber  gloves,  86 
traumatic  fever,  132 
Asthma  in  diagnosis  of  diseases  of  acces- 
sory nasal  sinuses,  491 
Ataxia,  abscess  of  brain  and,  351 

tmnors  of  brain  and,  351 
Atheromatous  cysts  of  scalp,  280 

treatment  of,  281 
Atrophy    of    inferior   turbinated    body, 
operations  for,  484 
of  skull,  307 

diagnosis  of,  309 
excentric,  308 

extracranial  pressure  and,  308 
intracranial  pressure  and,  307 
senile,  308 
treatment  of,  311 
Auto-intoxication,     intestinal,     surgical 

prognosis  and,  36 
Avulsion  of  scalp,  270 


INDEX 


829 


B 


Bacteria  causing  infection  of  wounds, 

82 
Bacterial  vaccines,  administration  of,  178 
making  pure  cultures,  175 
preparation  of,  174 

Wright's  method,  176 
sensitized,  178 
Ballenger's  swivel  knife,  479 
Banti's  disease,  blood  transfusion  in,  191 
Barlow's  experiments  with  radium,  216 
Basedow's  disease,  771 
Beck-Hanson's   restraining  jacket,   526, 

527 
Beck-Mueller  ether-vapor  and  vacuum 

apparatus,  528 
Beck's  conchotribe,  487 

modification  of  Sluder's  tonsil  opera- 
tion, 525 
obHteration  operation  on  antrum  of 

Highmore,   511 
operation  for  tumors  of  pharynx,  515 
osteoplastic  frontal  sinus  operation, 

498 
sphenoid  sounds,  497 
suction  apparatus,  492 
tonsil  clamp,  533 
knife,  532 
pillar  retractor,  531 
snare,  529 
wash-bottle,  492 
Bier's  intravenous  anesthesia,  111 
Billroth's  mixture,  96 
Birth  palsy,  brachial,  688 
Black's  chisel,  480 

Bladder  in  postoperative  treatment,  149 
Blandin-Nuhn,  glands  of,  cysts  of,  548 

treatment  of,  548 
Blastomycosis  of  scalp,  diagnosis  of,  from 

carcinoma,  291 
Blood  in  acute  otitis  media,  453 
culture  in  pyemia,  134 
in  septicemia,  134 
cysts  of  neck,  712 

of  scalp,  267,  283 
diseases  of,  roentgen  rays  in  treat- 
ment of,  281 
in  exophthalmic  goiter,  793 
supply  of  scalp,  263 
transfusion,  187 

in  acute  surgical  shock,   191 
in  anemia   compHcating  preg- 
nancy, 190 
in  Banti's  disease,  191 
donor  in,  194 
factors  of  safety  in,  205 
grouping  of  blood  in,  technic 

of,  199 
in  hemolytic  icterus,  191 
in  hemophiha,  191 
in  hemorrhages,  188 

compHcating  icterus,  190 
infectious  diseases,  190 
typhoid  fever,  190 
obscure,  189 


Blood  transfusion   in  hemorrhagic  dis- 
eases of  new-born,  191 
in  illuminating  gas  poisoning, 

192 
indications  for,  188 
methods  of,  200 
Percy's,  200 

description  of  tube,  201 
preparation    of    tube, 
201 
in  pernicious  anemia,  192 
preHminary  examination  in,  194 
reactions  following,  205 
in  secondary  anemia,  190 
in  septicemia,  191 
technic  of,  201 

tests  in,  agglutination,  194,  195 
hemolysis,  194 
hemolytic,  194 
in  toxemia,  191 

Vincent's  method  of  determin- 
ing   the    moss    grouping    of 
blood,  199 
Blood-pressure,  critical  level  of  in  shock, 
118 
surgical  prognosis  and,  32 
Bloodvessels  of  scalp,  diseases  of,  283 
Boils  of  neck,  706 

diagnosis  of,  706 
treatment  of,  706 
Bone   defect   and  subtemporal   decom- 
pression, 429 
forceps,  509 
Paget's  disease  of,  315 
Bowels  in  postoperative  treatment,  141, 

149 
Brachial  birth  palsy,  688 

etiology  of,  688 
prognosis  of,  688 
treatment  of,  688 
plexus  injuries,  680 
Brain,  abscess  of,  395 

ataxia  and,  351 
deafness  and,  349 
diagnosis  of,  395 
disorientation  and,  351 
dysmetria  and,  351 
fulminating,  395 
latent,  396 

nystagmus  and,  350,  470 
of  otitic  origin,  469 

after-treatment    of, 

471 
diagnosis  of,  470 
pulse  in,  470 
symptoms  of,  469 
treatment  of,  470 
word  blindness  in,  470 
radiology  in,  356 
relation  of  ear  to,  349 
stage  of  exacerbation  in,  396 
tinnitus  and,  349 
treatment  of,  397 
vertigo  and,  351,  470 
central  gray  matter  of,  tumors  of, 
diagnosis  of,  336 


830 


INDEX 


Brain,  cerebellopontine  angle  of,  tumors 
of,  diagnosis  of,  338 
cerebellum  of,  tumors  of,  diagnosis 

of,  337 
cerebral  localization  of,  329 

peduncles,  tumors  of,  diagnosis 
of,  340 
corpora    quadrigemina,    tumors   of, 

diagnosis  of,  340 
corpus  callosum  of,  tumors  of,  diag- 
nosis of,  337 
cysts,   diagnosis   of,    from   dermoid 

cysts  of  scalp,  280 
frontal  lobes  of,  tumors  of,  diagnosis 

of,  332 
hypophysis,  tumors  of,  diagnosis  of, 

340 
inflammation  of,  392 
medulla  ol)longata,  tumors  of,  diag- 
nosis of,  339 
meninges  of,  inflammations  of,.  392 

treatment  of,  394 
motor  zone  of,  tumors  of,  diagnosis 

of,  333 
occipital  lobe  of,  tumors  of,   diag- 
nosis of,  336 
pineal  gland,   tumors  of,   diagnosis 

of,  347 
pons,  tumors  of,  diagnosis  of,  339 
sensory  zone  of,  tumors  of,  diagnosis 

of,  333 
substance,  puncture  of,  386 
surgery,    shock    in,    surgical    prog- 
nosis and,  49 
syphilis  of,  404 

diagnosis  of,  404 
treatment  of,  405 
temporal  lobes  of,  tumors  of,  diag- 
nosis of,  335 
tumors  of,  ataxia  and,  351 

cerebrospiral  fluid  and,  354 
choked  disk  in,  352 
convulsions  in,  353 
deafness  and,  349 
diagnosis  of,  327 
disorientation  and,  351 
dysmetria  and,  351 
headache  in,  352 
lumbar  puncture  and,  354 
nystagmus  and,  350 
pulse  in,  353 
radiology  in,  356 
relation  of  ear  to,  349 
signs  of,  352 
stupor  in,  353 
sjTnptoms  of,  352 
tinnitus  and,  349 
treatment  of,  358 

intracranial  routes,  366 
vertigo  and,  351 
vomiting  in,  353 
ventricles  of,  puncture  of,  385 
Branchial  cyst,  diagnosis  of,  from  goiter, 

782 
Breast,  carcinoma  of,  radium  in  treat- 
ment of,  225 


Breast,   operations  on,  wound  infection 

in,  surgical  prognosis  and,  51 
Broca's   convolution,    tumors   of,    diag- 
nosis of,  332 
Bronchiectasis,  bronchoscopy  for,  747 
Bronchitis,  acute,  surgical  prognosis  and, 
36 
in  diagnosis  of  diseases  of  accessory 
nasal  sinuses,  491 
Bronchopneumonia,    surgical    prognosis 

and,  55 
Bronchoscope,  introduction  of,  743 
Bronchoscopy,  735,  743 
anesthesia  in,  736 
fluoroscopic,  756 
for  abscess  of  lung,  747 
for  bronchiectasis,  747 
for  extraction  of  foreign  bodies,  748 
mortality  from,  752 
results  of,  752 
tracheotomic,  756 
Brown's  operation  for  cleft  palate,  605 
for  double   harelip,   592 
of  separation  of  superior  maxil- 
lary bones  to  widen  the  nares 
for  improvement  of  respira- 
tory   and    other    conditions, 
571 
Burns  of  neck,  679 

treatment  of,  679 
Bursa,  sublingual,  hydrops  of,  550 
Bursal  cysts  of  neck,  712 


Calcic  pericementitis,  542 

Caput  obstipum,  669.     See  Wry-neck. 

Carbuncle  of  neck,  707 

treatment  of,  707 
of  scalp,  273 

operation  for,  274 
prognosis  of,  274 
vaccines  in,  184 
Carcinoma  of  breast,  radium  in  treat- 
ment of,  225 
of  esophagus,  radium  in  treatment 

of,  228 
of  face,  radium  in  treatment  of,  220 
malposed  unerupted  teeth  and,  558 
of  neck,  718 

diagnosis  of,  from  tuberculous 
cervical  lymphadenitis,  700 
of  parotid  gland,  radium  in  treat- 
ment of,  226 
of  pharynx,  operation  for,  663 

radium  in  treatment  of,  228 
of  pillars    of  fauces,  operation  for, 

663 
of  posterior  nares,  operation  for,  663 
of  rectum,  radium  in  treatment  of, 

228 
roentgen  rays  in  treatment  of,  255 
of  scalp,  289 

diagnosis  of,  291 

from  blastomycosis,  291 


INDEX 


831 


Carcinoma  of  scalp,  diagnosis  of,  from 
syphilis,  291 
from  tuberculosis,  291 
treatment  of,  291 
of  stomach,  radium  in  treatment  of, 

228 
of  thyroid  gland,  817 

diagnosis  of,  817 
treatment  of,  818 
of  tonsil,  operation  for,  662 

radium  in  treatment  of,  228 
of  uterus,  radium  in  treatment  of, 

229 
of  uvula,  operation  for,  663 
Cardiac  failure  theory  of  shock,  720 

signs  in  exophthalmic  goiter,  789 
Cardiospasm,  esophagoscopy  for,  765 
Caries  of  jaws,  treatment  of,  652 
Carotid  gland,  tumors  of,  720 
diagnosis  of,  721 
symptoms  of,  721 
treatment  of,  721 
Carrel's  experiments  with  radium,  212 
Cartilage  transplants,  648  • 

Catarrhal  inflammation,  127 
Catgut,  preparation  of,  89 

Bartlett's  method,  90 
Catheters,  disinfection  of,  88 
Cavernoma  of  skull,  322 
Cavernous  angioma  of  scalp,  287 
Cellulitis  of  neck,  707 
Cementoma,  555 

symptoms  of,  555 
Central  gray  matter  of  brain,  tumors  of, 

336 
Cephalhematoma,    diagnosis    of,     from 
pneumatocele,  278 
of  scalp,  266 
Cephalocele,  386 

diagnosis  of,  386 

from   dermoid    cysts  of   scalp, 

283 
from  hematoma  of  scalp,  267 
from  lipoma  of  scalp,  283 
treatment  of,  387 
Cephalohydrocele  of  scalp,  traumatic,  278 
diagnosis  of,  279 
treatment  of,  280 
Cerebellar  tumors,  treatment  of,  364 
Cerebellopontine  angle,  tumors  of,  338 

tumors,  treatment  of,  364 
Cerebellum,  tumors  of,  337 
Cerebral     exploration     in    subtemporal 
decompression,  432 
localization,  diagnosis  of  tumors  of 

brain  and,  329 
peduncles,  tumors  of,  340 
Cerebrospinal  fluid,  tumors  of  brain  and, 
354 
chemical    characteris- 
tics of,  356 
clarity  of,  355 
color  of,  355 
microscopical    exami- 
nation of,  356 
pressure  of,  355 


Cerebrospinal  fluid,  tumors  of  brain  and, 

Wassermann  reaction  and,  356 
Cervical  glands,   tuberculosis   of,   diag- 
nosis of,  for  wry-neck,  670 
lymphadenitis,  tuberculous,  699 
diagnosis  of,  699 

from  carcinoma,  700 
from    Hodgkin's    dis- 
ease, 699 
from  leukemia,  699 
from  pseudoleukemia, 

699 
from  syphilis,  699 
excision  of  glands  of  neck 

in,  701 
treatment  of,  700 
operative,  701 
nerves,  division  of,  in  treatment  of 

wry-neck,  673 
rib,  708 

treatment  of,  709 
Cheiloplasty,  581 
Chills  in  pyemia,  136 

in    sinus    thrombosis    complicating 
mastoiditis,  466 
Chloroform  anesthesia  in  acute  dilata- 
tion of  stomach  in  postoperative 
treatment,  156 
in  general  anesthesia,  94 
surgical  prognosis  and,  40 
Chloroma  of  skull,  325 
Choked  disk  in  tumors  of  brain,  352 
Cholesteatoma  of  skull,  322 
Chromicized     catgut,     preparation     of, 

89 
Circoid  aneurysm  of  scalp,  285 
Circulatory  symptoms  in  exophthalmic 

goiter,  789 
Circumscribed    infectious    labyrinthitis, 

464 
Cleft  palate,  600 

operations  for,  582,  601 
age  and,  607 
anesthesia  in,  612 
Brown's,  607 
clamps  in,  604 
Davies-CoUey,  605 
field  of  operation  in,  609 
first  aid  in,  582 
hemorrhage  and,  607 
median  flap  sliding,  607 
method  of  including  bone 
;        with  mucoperiosteum  in 
flap  formation,  605 
paring  the  fissure  borders 

in,  609 
phonation  and,  619 
position  of  patient  in,  609 
preparation    of    mucoperi- 

osteal  flaps  in,  612 
reversal  of  mucoperiosteum 

in  flap  formation,  P04 
sutures  in,  613 
transplantation    of    tissue 
to  cover  palate  openings, 
604 


832 


INDEX 


Cleft  palate,  postoperative  palate  defects 
in,  surgical  correction  of,  617 
treatment  of,  non-surgical,  600 
postoperative,  616 
surgical,  601 
Closed  method  of  anesthesia,  102 
Cocaiu  as  local  anesthetic,  108 
Cold  abscess  of  scalp,  diagnosis  of,  from 

hpoma,  283 
Coloboma  of  face,  579 
Composite  odontomas  of  jaws,  555 

treatment  of,  557 
Congenital  fistula  of  neck,  677 
treatment  of,  678 
lip  scars,  581 
Congestion  of  lungs,  acute  postoperative, 

surgical  prognosis  and,  55 
Contusions  of  scalp,  265 
of  skull,  294 

diagnosis  of,  294 
prognosis  of,  295 
Convulsions  in  tumors  of  brain,  353 
Coolidge  tube,  235 

anticathode  or  target  of,  237 
filament  of,  236 

current  transformer,  237 
control,  238 
Corpora  quadrigemina,  tumors  of,  340 
Corpus  callosum,  punctures  of,  383 
technic  of,  384 
tumors  of,  337 
Cough  in  goiter,  779 
Cranial  bones.     See  Skull. 
Craniocerebral  topography,  358 
Craniotabes,  308 
Cutaneous  horns  of  scalp,  281 

warts  of  scalp,  281 
Cyst,  branchial,  diagnosis  of,  from  goiter, 

782  _ 

Cystitis,  surgical  prognosis  and,  71 
Cysts  of  brain,  diagnosis  of,  from  dermoid 
cysts  of  scalp,  280 
dentigerous,  554 

symptoms  of,  554 
of  glands  of  Blandin-Nuhn,  548 

treatment  of,  548 
of  jaws,  547 

dermoid,  552 

compoimd,  552 
multilocular,  551 

diagnosis  of,  552 
prognosis  of,  552 
treatment  of,  552 
parasitic,  553 
periosteal,  551 

symptoms  of,  551 
treatment  of,  551 
proUferous,  552 

treatment  of,  552 
of  mouth,  547 

of  mucous  glands,  retention,  547 
symptoms  of,  548 
treatment  of,  548 
membrane,  deep-seated,  548 
diagnosis  of,  548 
symptoms  of,  548 


Cysts  of  mucous  membrane,  deep-seated, 
treatment  of,  548 
of  neck,  710 

blood,  712 

Imrsal,  712 

dermoid,  711 

diagnosis  of,  710 

echinococcus,  713 

embryonic,  711 

lymphatic,  713 

retention,  712 

treatment  of,  713 
of  scalp,  280 

atheromatous,  280 

blood,  267,  283 

dermoid,  280 

sebaceous,  280 
of  skull,  echinococcus,  322 


Dalrymple's     sign     in     exophthalmic 

goiter,  792 
Davies-CoUey  operation  for  cleft  palate, 

605 
Deafness,  abscess  of  brain  and,  349 

tumors  of  brain  and,  349 
Dentigerous  cysts,  554 

sjrmptoms  of,  554 
Dento-alveolar  abscess,  535 
etiology  of,  536 
pathology  of,  536 
streptococcus  viridaus  and,  536 
treatment  of,  538 
Dermoid  cysts  of  jaws,  552 
compound,  552 
of  neck,  711 
of  scalp,  280 

diagnosis    of,    from    brain 
cysts,  280 
from  cephalocele,  280 
from  lipoma,  282 
from  sebaceous  cysts, 

280 
from  serous'  cysts,  280 
Diabetes,  surgical  prognosis  and,  32 
Diet,  postoperative  treatment  and,  148 
Diffuse  infectious  labyrinthitis,  464 
Dilatation  of  stomach,  acute,  postopera- 
tive treatment  and,  155 
surgical  prognosis  and,  68 
Disinfection  of  catheters,  88 
of  instruments,  88 
of  skin,  86 

of  surgical  dressings,  91 
Disorientation,  abscess  of  brain  and,  351 

tumors  of  brain  and,  351 
Dissecting  lipoma  of  neck,  715 
treatment  of,  716 
Drinking  water,  goiter  and,  772 
Ductless  glands,  811 
Dull  ring  curette,  530 
Dura,  opening  of,  in  subtemporal  decom- 
pression, 432 
Dysmetria,  abscess  of  brain  and,  351 


INDEX 


833 


Dysmetria,  tumors  of  brain  and,  351 
Dysphagia  in  goiter,  779 


E 


Ear,  middle,  anatomy  of,  449 
inflammation  of,  450 
Echinococcus  cysts  of  neck,  713 
of  skull,  322 

treatment  of,  322 
Edema  in  acute  otitis  media,  451 

in  exophthalmic  goiter,  792 
Ehrlich's  side  chain  theory,  169 
Elephantiasis  of  nerves  of  scalp,  283 
Embolism,    fat,    theory   of   etiology   of 
shock,  118 
pulmonary,  postoperative  treatment 

and,  161 
surgical  prognosis  and,  57 
Embryonic  cysts  of  neck,  711 
Emetin  in  treatment  of  pyorrhea  alveo- 

laris,  546 
Emphysema  of  scalp,  277 
Empyema,  vaccines  in,  185 
Enchondroma  of  neck,  717 
Endameba   gingivalis,    pyorrhea   alveo- 

laris  and,  543 
Endoneural  anesthesia,  112 
Endoscopy,  asepsis  in,  738 

position  of  patient  in,  738 
Endothelioma  of  scalp,  293 
Enucleation  in  treatment  of  goiter,  783 
Epipharynx,  operations  on,  513 
Epithehal  odontomas  of  jaws,  554 
symptoms  of,  554 
tumors,  radium  in  treatment  of,  220 
Epithelioma  of  scalp,  289 
Epuhs,  557,  655 

diagnosis  of,  558,  655 
differential,  655 
Erysipelas  of  scalp,  272 
headache  in,  273 
prognosis  of,  273 
pulse  in,  273 
treatment  of,  273 
vomiting  in,  273 
vaccines  in,  185 
Esophagoscope,  introduction  of,  756 
Esophagoscopy,  756 

for  cardiospasm,  765 
for  foreign  bodies,  762 
for  hiatal  esophagismus,  765 
for  stricture  of  esophagus,  765 
for  tumors  of  esophagus,  765 
Esophagus,  foreign  bodies  in,  esophagos- 
copy for,  762 
stricture  of,  esophagoscopy  for,  765 
tmnors  of,  esophagoscopy  for,  765 
Ether  and  chloroform  in  general  anes- 
thesia, 96 
in  general  anesthesia,  94 
surgical  prognosis  and,  38 
Ethmoid  punch,  494 
Ethmoidal  labyrinth,  operations  on,  512 
Ethyl  chloride  in  general  anesthesia,  95 
VOL.  I — 53 


Eucain  as  local  anesthetic,  109 
Excision  in  treatment  of  goiter,  783 
Exenteration  in  treatment  of  goiter,  784 
Exophthalmic  goiter,  786,  814 
anesthesia  in,  795,  797 
blood  in,  793 
cardiac  signs  in,  789 
Dalrymple's  sign  in,  792 
diagnosis  of,  793 
differentiation  of,  from  thyreo- 
toxicosis, 815 
edema  in,  792 
etiology  of,  788 
exophthalmos  in,  791 
V.  Graefe's  sign  in,  793 
injection  in,  technic  of,  799 
hgation  in,  801 
mental  depression  in,  790 

irritabiUty  in,  790 
metaboHsm  and,  792 
Moebius's  sign  in,  792 
muscular  weakness  in,  791 
nervous  excitabiUty  in,  790 
skin  in,  792 
Stellwag's  sign  in,  792 
sweating  in,  792 
symptoms  of,  789 
circulatory,  789 
nervous,  790 
ocular,  791 
vasomotor,  792 
tachycardia  in,  789 
thjToid  murmurs  in,  789 
thyroidectomy  in,  802 
treatment  of,  793,  817 

collapse  of  trachea  in,  798 
hemorrhage  and,  798 
injury    to    parathyroid 
glands  and,  798 
to  pleura  in,  799 
to  recurrent  laryngeal 
nerves  and,  798 
postoperative      hyperthy- 
roidism and,  797 
shock  and,  797 
surgical,  794 
tremor  in,  790 
Exophthalmos  in  exophthalmic  goiter,  791 
Extracranial    incision    in    subtemporal 

decompression,  429 
Extremities,    operations    on,    shock   in, 

sm-gical  prognosis  and,  50 
Exudation  in  inflammation,  126 


Face,  carcinoma  of,  radium  in  treatment 
of,  220 
coloboma  of,  579 
operations  on,  wound  infection  in, 

surgical  prognosis  and,  51 
surgery  of,  535 
Facial  paralysis,  nerve  anatomosis  for, 

689 
Fat  embolism,  surgical  prognosis  and,  59 


834 


INDEX 


Fat    embolism     theorv    of    etiology   of 

shock,  118 
Fauces,  pillars  of,  carcinoma  of,  o])era- 

tion  for,  663 
Fever  in  acute  otitis  media,  453 
aseptic  traumatic,  132 
as  an  immunity  reaction,  137 
in  pyemia,  136 
in    sinus    thrombosis    complicating 

mastoiditis,  466 
surgical,  131 

nature  of,  131 
Fibroma  of  neck,  715 

of  scalp,  281 
Fibrous  odontoma  of  jaws,  555 
symptoms  of,  555 
Fistula  in  infectious  labyrinthitis,  464 
of  neck,  congenital,  677 

treatment  of,  678 
Fistulas,  intestinal,  postoperative,  sur- 
gical prognosis  and,  72 
Fluoroscopic  bronchoscopy,  756 
Focal  infection,  examination  of  mouth 

with  reference  to,  540 
Follicular  odontomas  of  jaws,  554 
compound,  555 

diagnosis  of,  555 
symptoms  of,  554 
Foreign  bodies  in  esophagus,  esophago- 
scopy  for,  762 
in  larynx,  cUrect  laryngoscopy 
for,  741 
Fractures  of  jaws,  623 

complications  of,  630 
etiology  of,  623 
of  neck  of  condyle  of,  635 
period  of  fixation  in,  631 
pseudoarthrosis  and,  637 

treatment  of,  638 
ramus  of,  635 

reduction  of  fracture  in,  631 
symptoms  of,  624 
treatment  of,  624 

Kingsley's  method  of,  629 
preparation     of     cast     of 
mouth    for    splint    con- 
struction, 629 
temporary  splint  in,  628 
army,  629 
varieties  of,  623 
war  injury,  636 
of  skull,  295 

of  base,  300 
comminuted,  297 
of  external  table,  299 
fissured,  296 
hemorrhage  in,  300 
of  internal  table,  299 
prognosis  of,  303 
simple,  296 
sjonptoms  of,  300 
treatment  of,  303 
of  vault,  compound,  298 
Freer's  elevator,  478 
long  retractor,  509 
septum  knife,  477 


Frontal  lobes,   tumors  of,  diagnosis  of, 
332 
sinus  nasal  sound,  496 
operations  on,  498 

Beck's  osteoplastic,  498 

after-treatment  in,  503 
Killian's,  506 

tifter-treatmont     in, 
507 
Lothrop's,  504 

after-treatment     in, 
506 
Furuncle,  acute  otitis  media  and,  452 

vaccines  in,  182 
Funmculosis  of  neck,  706 
diagnosis  of,  706 
treatment  of,  706 


G 


Gangrenous  inflammation,  127 

Gas  pains  complicating  anesthesia,  105 

Gasserian  ganglion,  tumors  of,  removal 

of,  383 
Gigantism,  313 
Gingivitis,  interstitial,  542 
Glands  of  Blandin-Nuhn,  cysts  of,  548 

treatment  of,  548 
Ghoma  of  hypophysis,  345 
Goiter,  771,  812 

classification  of,  773 
clinical  history  of,  771 
drinking  water  and,  772 
etiology  of,  772 
exophthalmic,  786,  814 
anesthesia  in,  795,  797 
blood  in,  793 
cardiac  signs  in,  789 
closure  of  wound  in,  806,  816 
Dalrymple's  sign  in,  792 
diagnosis  of,  793 
differentiation  of, 

from  thyreotoxicosis,  815 
drainage  in,  806,  816 
edema  in,    792 
etiology  of,  788 
exophthalmos  iff,  791 
V.  Graefe's  sign  in,  791 
injection  in,  technic  of,  799 
ligation  in,  801 
mechanism  of,  815 
mental  depression  in,  790 

irritabihty  in,  790 
metabolism  in,  792 
Moebius's  sign  in,  792 
murmurs  of  thyroid  in,  789 
muscular  weakness  in,  791 
nervous  excitability  in,  790 
skin  in,  792 
Stellwag's  sign  in,  792 
sweating  in,  792 
symptoms  of,  789 
circulatory,  789 
nervous,  790 
ocular,  791 


INDEX 


835 


Goiter,     exophthalmic,     symptoms    of, 
vasomotor,  792 
tachycardia  in,  789 
thyroidectomy  in,  802 

incision  in,  802,  812 
treatment  of,  793,  817 

collapse  of  trachea  in,  798 
hemorrhage  and,  798 
injury      to       parathyroid 
glands  and,  798 
to  pleura  in,  799 
to  recurrent  laryngeal 
nerves  and,  798 
postoperative      hyperthy- 
roidism and,  797 
shock  and,  797 
surgical,  794 
tremor  in,  790 
hyperplastic  atoxic,  776,  786 

toxic,  776,  786.     >See  Goiter,  ex- 
ophthalmic, 
non-hyperplastic  atoxic,   706,    710. 
See  Goiter,  simple, 
toxic,  775,  784 

treatment  of,  785 
simple,  778 

cough  in,  779 
diagnosis  of,  779 

-from  branchial  cyst,  782 
from    lymphosarcomata, 
782 
diffuse,  779 
dysphagia  in,  779 
enucleation  in,  783 
excision  in,  783 
exenteration  in,  784 
involvement  of  nerves  in,  779 
ligation  of  arteries  in,  784 
nodular,  780 
pain  in,  779 
resection  in,  784 
symptoms  of,  778 
treatment  of,  782 
operative,  783 

indications  for,  783 
Gonorrheal  arthritis,  surgical  history  of, 
771 
vaccines  in,  181 
v.  Graefe's  sign  in  exophthalmic  goiter, 

791 
Graves's  disease,  771,  786,  814 
Greenwald's  ethmoid  punch,  494 
Gunning's  interdental  splint,  625 
Gunshot  wounds  of  scalp,  271 

of  skull,  304 
Gutta-percha,  preparation  of,  90 
Gynecological  operations,  wound  infec- 
tion in,  surgical  prognosis  9,nd,  52 

H 

Ha.jek-Ballenger  elevator,  478 
Halle  cranial  protector,  502 
Harmxiond's  sphnt,  628 
Hampson's  quantimeter,  249 
Hands,  preparation  of,  84 


HareHp,  577 

development,  577 
double,  579,  590 

operations  for,  593 
Brown's,  594 
etiology  of,  578 
operations  for,  582 

after-treatment  in,  595 
age  and,  583 

correction  of  postoperative  Up 
and  associated  nasal  defects 
in,  596 
first  aid  in,  582 
fixation  of  nasal  septum  and 

ala  in,  585 
hues  of  incision  in,  585 
hp  compression  clamps  in,  585 
position  in,  584 

postoperative  control  of  dress- 
ing in,  588 
relief  of  tension  in,  589 
sutures  in,  586 

treatment  of  nasal  septum  and 
vomer  in,  590 
single,  579 
varieties  of,  579 
Head  operations  on,  wound  infection  in, 

surgical  prognosis  and,  51 
Headache   in   diagnosis   of   diseases    of 
accessory  nasal  sinuses,  490 
in  erysipelas  of  scalp,  273 
malposed  unerupted  teeth  and,  558 
in  otitic  meningitis,  468 
in  tumors  of  brain,  352 
Heart  disease,  surgical  prognosis  and,  31 
Heffernan's  nasal  speculum,  477 
Heinz -Bauer  quahmeter,  246 
Hematoma,  operations  for  deviation  of 
nasal  septum  and,  482 
of  sCalp,  265 
deep,  265 
diagnosis  of,  267 

from  cephalocele,  267 
from  hernia  cerebri,  267 
from   meningocele   spuria, 
267 
subcutaneous,  265 
treatment  of,  267 
Hemolysis  test  in  blood  transfusion,  194 
Hemolytic  icterus,  blood  transfusion  in, 
191 
test  in  blood  transfusion,  194 
HemophiUa,  blood  transfusion  in,  191 

surgical  prognosis  and,  34 
Hemorrhage,  117 

blood  transfusion  in,  188 
compHcating  icterus,    blood    trans- 
fusion in,  190 
infectious  diseases,  blood  trans- 
fusion in,  190 
typhoid    fever,     blood     trans- 
fusion in,  190 
definition  of,  117 
diagnosis  of,  from  shock,  121 
in  fractures  of  skull,  300 
obscure,  blood  transfusion  in,  189 


836 


INDEX- 


Hemorrhage,    postoperative     treatment 
and,  151 
in  pyemia,  136 
surgical  prognosis  and,  43 
in  treatment  of  exophthalmic  goiter, 
798 
Hemorrhagic  diseases  of  newborn,  blood 
transfusion  in,  191 
inflammation,  127 
Hernia  cerebri,  391 

diagnosis   of,    from   hematoma 

of  scalp,  267 
treatment  of,  391 
operations  for,   wound  infection  in, 

surgical  ])rognosis  and,  51 
postoperative       ventral,       surgical 
prognosis  and,  68 
Hiatal  esophagismus,  esophagoscopy  for, 

765 
Hiccough  in  postoperative  treatment,  157 
Hodgkin's    disease,    719 
diagnosis  of,  720 

from  tuberculous  cervical 
lymphadenitis,  699 
roentgen  rays  in  treatment  of, 
261 
Holzknecht  quantimeter,  248 
Horns,  cutaneous,  of  scalp,  281 
Horsehair,  preparation  of,  89 
Hydrocephalus,  388 
diagnosis  of,  388 
treatment  of,  389 
Hydrops  of  sublingual  bursa,  550 
Hyperpituitarism,  tumors  of  hypophysis 

and,  341,  342 
Hyperplasia  of  thyroid  gland,  812 
H>T)erplastic  atoxic  goiter,  776,  786 

toxic  goiter,  776,  786 
Hyperthyroidism,     postoperative,     and 
treatment    of    exophthalmic 
goiter,  797 
treatment  of,  809 

after-treatment  in,  809 
Hypertrophy  of  inferior  turbinated  body, 
operations  for,  484 
of  thymus  gland,  822 

diagnosis  of,  823 
thjTnectomy  in,  824 
treatment  of,  824 

x-rays  in,  823,  824 
Hypophysectomy  in  tumors  of  hypoph- 
ysis, 374 
Hypophysis,  ghoma  of,  345 
sarcoma  of,  344 
tumors  of,  340 

acromegaly  and,  341,  343 
hyperpituitarism  and,  341,  342 
perversion  of  secretion  in,  340 
pressure  symptoms  in,  344 
treatment  of,  367 

choice  of  operation  in,  378 
hypophysectomy  in,  374 
indications    for    operation 

in,  381 
infranasal  route  in,  372 
intracranial  routes  in,  368 


Hypophysis,    tumors  of,    treatment   of, 
supranasal  route  in,  371 
through  the  mouth,  378 
transphenoidal  methods  in, 
371 


Icterus,  hemolytic,  blood  transfusion  in, 
191 
hemorrhages  in,   blood  transfusion 
in,  190 
Illuminating  gas  poisoning,  blood  trans- 
fusion in,  192 
Incised  wounds  of  cranial  bones,  293 
Infections,  septic,  malignant,  132 
Infectious     diseases,     hemorrhages     in, 
blood  transfusion  in,  190 
labyrinthitis,  mastoiditis  and,  463 
circumscribed,  464 
diagnosis  of,  465 
diffuse,  464 
fistula  in,  464 
hearing  in,  463 
nausea  in,  463 
treatment  of,  465 
vertigo  in,  463 
vomiting  in,  463 
Inferior    turbinated    body,    atrophy  of, 
484 
hypertrophy  of,  484 
operations  on,  484 

actual  cautery  in,  485 
crushing  in,  486 
resection  in,  487 
Infiltration  anesthesia.  111 
Inflammation,  125 
acute,  127 
catarrhal,  127 
chronic,  127 
definition  of,  125 
etiology  of,  125 
exudation  in,  126 
gangrenous,  127 
heat  in,  127 
hemorrhagic,  127 
interstitial,  127 
metastatic,  127 
of  middle  ear,  450 
pain  in,  127 
parenchymatous,  127 
pathology  of,  126 
perivascular  tissues  in,  126 
pseudomembranous,  127 
purulent,  127 
redness  in,  127 
specific  infective,  127 
subacute,  127 
suppurative,  127 
swelling  in,  127 
symptoms  of,  127        - 
traumatic,  127 
treatment  of,  127 
Inflammations  of  brain  and  meninges, 
392 


INDEX 


837 


Inflammatory  diseases,  roentgen  rays  in 

treatment  of,  260 
Intranasal  route  in  operation  for  tumors 

of  hypophysis,  372 
Instruments,  after-care  of,  88 

disinfection  of,  88 
Interdental  splints,  625 
Interstitial  gingivitis,  542 

inflammation,  127 
Intestinal     auto-intoxication,      surgical 
prognosis  and,  34 
fistulas,      postoperative,      surgical 

prognosis  and,  72 
obstruction,  postoperative,  surgical 
prognosis  and,  66 
treatment  and,  152 
mechanical,  153 
septic,  154 
tract,  operations  on,  wound  infec- 
tion in,  surgical  prognosis  and,  52 
Intracranial  blood  sinuses,  thrombosis  of, 
401 
diagnosis  of,  401 
treatment  of,  402 
routes  in  operation  for  tumors  of 
hypophysis,  367 
Intrapharyngeal  anesthesia,  100 
Intrathoracic  operations,  shock  in,  sur- 
gical prognosis  and,  49 
Intratracheal  insufflation  anesthesia,  99 
tube,    introduction    of,    direct 
larjTigoscopy  for,  743 
Intravenous  anesthesia,  100 

Bier's,  111 
Ionic    medication,    pyorrhea    alveolaris 
and,  545 


Jaw,    deformities    of,    due    to    tumor 
growths  and  tumor  pressure,  568 
lower,  chronic  dislocation  of,  Riley's 
appliance  for,  630 
extension  on,  568 
prognathous,  567 

bilateral  resections  to  re- 
duce, 567' 
unilateral  resection  of,  568 
tumors  of,  radium  in  treatment  of, 
219 
Jaws,  caries  of,  treatment  of,  652 

complete  loss  of  segments  of  bone 

from,  638 
cysts  of,  547 

dermoid,  552 

compound,  552 
multilocular,  551 

diagnosis  of,  552 
prognosis  of,  552 
treatment  of,  552 
parasitic,  553 
periosteal,  551 

symptoms  of,  551 
treatment  of,  551 
proliferous,  552 

treatment  of,  552 


Jaws,  fractures  of,  623 

complications  of,  630 
etiology  of,  623 
period  of  fixation  in,  631 
pseudoarthrosis  and,  637 

treatment  of,  638 
reduction  of  fractures  in,  631 
s>Tnptoms  of,  624 
treatment  of,  624 

Kingsley's  method  of,  629 
preparation     of     cast     of 
mouth    for    splint    con- 
struction, 629 
temporary  splint  in,  628 
army,  629 
war  injury,  636 
neck  of  condyle  of,  fractures  of,  635 
necrosis  of,  649 

diagnosis  of,  652 
etiology  of,  649 
pathology  of,  649 
periostitis  and,  649 
symptoms  of,  652 
treatment  of,  652 
odontoma  of,  553 
composite,  555 

treatment  of,  557 
epithelial,  554 

symptoms  of,  554 
fibrous,  555 

symptoms  of,  555 
follicular,  554 

compound,  555 

diagnosis  of,  555 
symptoms  of,  554 
radicular,  555 
ramus  of,  fractures  of,  635 
teratomas  of,  552 
Jaundice,  surgical  prognosis  and,  35 


K 


Keloids  of  scalp,  282 

differential  diagnosis  of,  282 
treatment  of,  282 
Kernig's  sign  in  otitic  meningitis,  468 
Kidneys,  effects  of  anesthesia  on,   sur- 
gical prognosis  and,  41 
Killian's  frontal  sinus  operation,  506. 

after-treatment  in,  507 
technic  of,  506 
nasal  speculum,  479 
Kingsley's  interdental  splint,  623 
Kocher's  operation  in  treatment  of  wry- 
neck, 673 
for  tumors  of  tongue,  659 
Krause's  nasal  snare,  494 


Labyrinth,  ethmoidal,  operations  on,  512 
Labyrinthitis,      infectious,     mastoiditis 
and,  463 
circumscribed,  464 


838 


INDEX 


Labyrinthitis,     infectious,      mastoiditis 
and,  diagnosis  of,  465 
diffuse,  464 
fistula  in,  464 
hearing  in,  463 
nausea  in,  463 
treatment  of,  465 
vertigo  in,  463 
vomiting  in,  463 
La  Force's  hemostatic  tonsillectome,  525 
modification  of  Sluder's  tonsil  opera- 
tion, 525 
Laryngeal  growths,  removal  of,  by  direct 
larjTigoscopy,  742 
nerves,     recurrent,     injury    to,     in 
treatment  of  exophthalmic  goiter, 
798 
operations,  shock  in,  surgical  prog- 
nosis and,  49 
Laryngectomv,  partial,  729 

total,  730 
Laryngoscopy,  direct,  735,  739 
anesthesia  in,  736 
for  introduction  of  intratracheal 
insufflation  anesthesia  tubes, 
743 
instnunents  for,  736 
removal  of  benign  growths  from 
larjTix  by,  742 
of     foreign     bodies     from 

larjTix  by,  741 
of   lars'ngeal   growths  by, 
742  ■ 
Larynx,  foreign  bodies  in,  direct  larj-n- 
goscopy  for,  741 
growths  in,  direct  laryngoscopy  for, 

742 
injuries  of,  690 
operations  on,  727 
Leontiasis  ossea,  313 

diagnosis  of,  313 

from  acromegaly,  313 
from    osteitis    deformans, 

313 
from  sarcoma,  313 
Leukemia,  diagnosis  of,   from  tubercu- 
lous cervical  hTiiphadenitis,  699 
Leukocytosis  in  sinus  thrombosis  com- 
plicating mastoiditis,  466 
Leukoplakia,    radium    in    treatment  of, 

227 
Lewis's  double  screw,  529 
Ligation  of  arteries  in  treatment  of  goiter, 

784,  801 
Lip  scars,  congenital,  581 
Lipoma  of  neck,  715 

dissecting,  715 

treatment  of,  716 
of  scalp,  282 

diagnosis  of,  from  cephalocele, 
283 
from  cold  abscess,  283 
from  dermoid  cj'sts,  282 
Lipovaccines,  171 

Liver,  effects  of  anesthesia  on,  surgical 
prognosis  and,  41 


Lobar  pneumonia,  surgical  prognosis  and, 

55 
Loher's  splint,  627 
Lombard's  bone  forceps,  509 
Lothrop's  frontal  sinus  operation,  504 

after-treatment  in,  506 
technic  of,  504 
Luc-Briinning's  septum  forceps,  481 
Ludwig's  angina,  707 
Lumbar  puncture,  timaors  of  brain  and, 
354 
technic  of,  355 
Lung,  abscess  of,  bronchoscopy  for,  743 
Lungs,  congestion  of,  acute  postopera- 
tive, surgical  prognosis  and,  55 
effects    of    anesthesia    on,    surgical 
prognosis  on,  42 
Lupus  of  scalp,  diagnosis  of,  from  syphilis, 

276 
LjTnphadenitis,  tuberculous  cervical,  699 
diagnosis  of,  699 

from  carcinoma,  700 
from    Hodgkin's    dis- 
ease, 699 
from  leukemia,  699 
from  pseudoleukemia, 

699 
from  syphilis,  699 
excision  of  glands  of  neck 

in,  701 
treatment  of,  700 
operative,  701 
Lymphangio-endothelioma  of  scalp,  293 
Lj-mphatic  cysts  of  neck,  713 
LxTiiphatics  of  scalp,  264 
Lymphosarcomata,    diagnosis    of,    from 
goiter,  782 


M 


Maier's  dull  ring  curette,  530 
Malformation     of     mandible     due     to 
arrested  or  perverted  development  of, 
561 
Malignant  septic  infections,  132 
Malposed  unerupted  teeth,  558 
carcinoma  and,  558 
diagnosis  of,  560 
headache  and,  558 
neuralgia  and,  558 
neurasthenia  and,  558 
pathological    significance 

of,  558 
radiography  and,  561 
sarcoma  and,  558 
treatment  of,  561 
Mandible,    development    of,    endocrine 
disorders  and,  561 
loss    or    deficiency    of    normal 
physiologic  activity  and  an- 
tagonizing mechanical  influ- 
ences and,  563 
prenatal  tendency  to  arrest  of, 

561 
traumatic  injuries  and,  563 


INDEX 


839 


Mandible,    malformations    of,  defective 
tooth  eruption  and, 
565 
treatment  of,  566 
due   to   arrested   or   perverted 
development,  561  ! 

surgical  correction  of,  563  I 

Martin's  splint,  628 
Mastoid,   tuberculosis  of,   diagnosis  of, 

from  pneumatocele  of  scalp,  278 
Mastoiditis,  acute  otitis  media  in,  449 
blood  examination  in, 
453  j 

diagnosis  of,  453  j 

discharge  in,  bacterio-  ' 
logical   findings   in, 
452 
edema  in,  451 
fever  in,  453 
furuncle  and,  452 
operation  in,  455 
pain  in,  450 
symptoms  of,  450 
tenderness  on  pressure 

in,  450 
treatment  of,  454 
chronic  suppurative  otitis  media  in, 
457 
diagnosis  of,  458 
discharge  in,  458 
operation  in,  460 
treatment  of,  460 
infectious  labyrinthitis  and,  treat- 
ment of,  465 
otitic  meningitis  and,  467 
diagnosis  of,  469 
headache  in,  468 
Kernig's  sign  in,  468 
rigidity  of  neck  in,  468 
symptoms  of,  468 
vomiting  in,  468 
treatment  of,  469 
sinus  thrombosis  and,  466 
chill  in,  466 

fever  in,  466  j 

leukocytosis  in,  466  I 

symptoms  of,  466 
treatment  of,  467 
Maxilla,  correction  of  related  nasal  and 
developmental  defects  of,  by  separa- 
tion of  superior  maxillae,  568 
Maxillse,  separation  of,  immediate  effect , 

of,  576 
Maxillary    bones,     immediate    surgical 
separation  of,  to  widen  the  nares  for 
the  improvement  of  respiratory  and  i 
other  conditions,   571  ' 

MeduUa  oblongata,  tumors  of,  339 
Meningitis,  otitic,  mastoiditis  and,  467 
diagnosis  of,  469 
headache  in,  468 
Kernig's  sign  in,  468 
rigidity  of  neck  in,  468 
symptoms  of,  468 
treatment  of,  469 
vomiting  in,  468 


Meningitis,  tuberculous,  404 
diagnosis  of,  404 
treatment  of,  404 
Meningocele,  diagnosis   of,    from  pneu- 
matocele, 277 
spuria  (traumatic)  of  scalp,  278 
diagnosis  of,  279 

from  hematoma,  267 
treatment  of,  280 
Menopause,  artificial,  surgical  prognosis 

and,  73 
Mental  depression  in  exophthalmic  goiter, 
790 
irritabihty  in  exophthalmic  goiter, 
790 
Mesopharjmx,  operations  on,  518 
Metabohsm,   exophthalmic   goiter   and, 

792 
Metastatic  inflammation,  127 
Metzer  and  Auer's  method  of  anesthesia, 

99 
Michel's  chp,  488 
Moebius's  sign  in  exophthalmic  goiter, 

792 
Moi-phin  and  atropin  in  local  anesthesia, 

108 
Motor  zone  of  brain,  tumors  of,  diagnosis 

of,  333 
Mouth,  cysts  of,  547 

examination  of,  focal  infection  and, 

540 
operations  on,  major,   655 
postoperative  treatment  and,  141 
trench,  546 

treatment  of,  547 
Mucous  glands,  cysts  of,  retention,  547 
symptoms  of,  548 
treatment  of,  548 
membrane,  cysts  of,  deep-seated,  548 
diagnosis  of,  548 
symptoms  of,  548 
treatment  of,  548 
Multilocular  cysts  of  jaws,  551 
diagnosis  of,  552 
prognosis  of,  552 
treatment  of,  552 
Muscles  of  scalp,  264 
Muscular    weakness    in    exophthalmic 

goiter,  791 
Myelogenous  sarcoma  of  skull,  323 
Myeloma  of  skull,  325 
Myoma    of    uterus,    roentgen    rays    in 

treatment  of,  260 
Myxedema,  772,  813 


N 


Nares,  posterior,  carcinoma  of,  opera- 
tion for,  663 
Nasal  accessory  sinuses,  diseases  of,  diag- 
nosis of,  asthma 
in,  491 
bronchitis  in,  491 
headache  in,  490 
pain  in,  490 


840 


INDEX 


Nasal    accessorj'    sinuses,    diseases    of, 
diagnosis       of, 
pus  in,  491 
roentgenograms 

in,  490 
transillumination 
in,  491 
treatment  of,  491 
operations  on,  493 

after-treatment     in, 

497 
anesthesia  in,  493 
sounding  of  sinuses  in, 

495 
technic  of,  493 
surgery  of,  489 
polypi,  517 

treatment  of,  517 
septum,  treatment  of,  in  operations 

for  harelip,  590 
snare,  494 

speculum,  Heffernan's,  477 
Killian's,  479 
Nasopharynx,    postoperative    treatment 

and,  141 
Nausea  complicating  anesthesia,  105 
in  infectious  labyrinthritis,  463 
postoperative,  anesthesia  and,  42 
treatment  and,  147 
Neck,  abscesses  of,  707 

treatment  of,  708 
actinomycosis  of,  684 
diagnosis  of,  694 

from  syphilis,  695 
treatment  of,  695 
aneurysms  of,  690 
diagnosis  of,  690 
treatment  of,  692 
angioma  of,  716 
bloodvessels  of,  injuries  of,  680 
boils  of,  706 

diagnosis  of,  706 
treatment  of,  706 
burns  of,  679 

treatment  of,  679 
carbuncle  of,  707 

treatment  of,  707 
carcinoma  of,  718 

diagnosis  of,  from  tuberculous 
cervical  lymphadenitis,  700 
celluhtis  of,  707 
chronic    inflammatory    processes 

affecting,  697 
cysts  of,  710 
blood,  712 
bursal,  712 
dermoid,  711 
diagnosis  of,  710 
echinococcus,  713 
embryonic,  711 
l\Tnphatic,  713 
retention,  712 
treatment  of,  713 
enchondroma  of,  717 
fibroma  of,  715 
fistula  of,  congenital,  677 


Neck,  fistula  of,   congenital,  treatment 
of,  678 
furunculosis  of,  706 
diagnosis  of,  706 
treatment  of,  706 
glands  of,  excision  of,  in  tuberculous 

cervical  lymphadenitis,  701 
injuries  of,  679 
lipoma  of,  715 

dissecting,  715 

treatment  of,  716 
nerves  of,  injuries  of,  680 
neuroma  of,  716 
operations  on,  724 

anesthesia  in,  726 
protection  of  field  in,  725 
skin  incisions  in,  726 
.  ^    wound    infection    in,    surgical 

prognosis  and,  51 
rigidity    of,    in    otitic    meningitis, 

468 
sarcoma  of,  719 
syphilis  of,  695 

diagnosis  of,  696 

from  actinomycosis,  695 
from  tuberculous    cervical 
lymphadenitis,  699 
treatment  of,  697 
teratoma  of,  711 
tumors  of,  710 
benign,  714 

treatment  of,  717 
malignant,  718 

treatment  of,  722 
palliative,  722 
veins  of,  injuries  of,  680 
Necrosis  of  jaws,  649 

diagnosis  of,  652 
etiology  of,  649 
pathology  of,  649 
periostitis  and,  649 
sjnnptoms  of,  652 
treatment  of,  652 
Nephritis  complicating  anesthesia,  105 
Nerve  exhaustion  theory  of  etiologv  of 

shock,  118 
Nerves,    injuries    of,  surgical    prognosis 
and,  73 
involvement  of,  in  goiter,   779 
of  scalp,  265 

diseases  of,  283 

diagnosis  of,  283 
treatment  of,  283 
Nervous    excitability    in    exophthalmic 
goiter,  790 
symptoms  in   exophthalmic   goiter, 

790 
system,  effect  of  anesthesia  on,  sur- 
gical prognosis  and,  42 
Neuralgia,    malposed    imerupted    teeth 

and,  558 
Neurasthenia,  malposed  unerupted  teeth 

and,  558 
Neurofibroma  of  scalp,  283 
Neuroma  of  neck,  716 

plexiform,  of  scalp,  283 


INDEX 


841 


Neuroses,  postoperative,  surgical  prog- 
nosis and,  75 
Neiu"otic   temperament,    surgical   prog- 
nosis and,  28 
Nevi,  vascular,  of  scalp,  286 
Newborn,  hemorrhagic  diseases  of,  blood 

transfusion  in,  191 
Nitrous  oxide  in  general  anesthesia,  95 

surgical  prognosis  and,  40 
Non-hyperplastic  atoxic  goiter,  774,  778 

toxic  goiter,  775,  784 
Non-neoplastic  swellings  of  scalp,  277 
Nose,  anatomy  of,  474 

septum  of,  deviation  of,  476 
operations  for,  476 

after-treatment     in, 

482 
comph cations  of,  482 
hematoma  and,  482 
technic  of,  476 
tonsilUtis  and,  483 
surgery  of,  473 
Novocain  as  local  anesthetic,  109 
Nystagmus,  abscess  of  brain  and,  350,  470 
tumors  of  brain  and,  350 


Obesity,  surgical  prognosis  and,  30 
Occipital  lobe  of  brain,  timiors  of,  336 
Ocular  symptoms  in  exophthamic  goiter, 

791 
Odontoma  of  jaws,  553 
composite,   555 

treatment  of,  557 
epithelial,  554 
fibrous,  555 
folhcular,  554 

compound,  555 
radicular,  555 
Open-drop  method  anesthesia,  98 
Operating  room,  after-care  of,  88 

preparation  of,  88 
Opsonic  index,  173 
Opsonins,  172 
Oral  anesthesia,  102 
Osteitis  deformans  of  skull,  315 

diagnosis    of,    from    leon- 
tiasis  ossea,  313 
Osteoma  of  skull,  320 

diagnosis  of,  321 
treatment  of,  322 
Osteomyelitis,  acute  pyogenic,  of  skull, 
315 
diagnosis  of,  316 
prognosis  of,  316 
treatment  of,  316 
vaccines  in,  185 
Osteoperiosteal  grafts,  643 
Osteoplastic    frontal    sinus    operation. 
Beck's,  498 
after-treatment 

in,  503 
technic  of,  498 
Otitic  meningitis,  mastoiditis  and,  467 


Otitic  meningitis,  mastoiditis  and,  diag- 
nosis of,  469 
headache  in,  468 
Kernig's  sign  in,  468 
rigidity  of  neck  in.  468 
symptoms  of,  468 
treatment  of,  469 
vomiting  in,  468 

Oxycephalia,  391 

Oxygen  in  general  anesthesia,  95 
surgical  prognosis  and,  40 


Pachymeningitis  externa,  392 

interna  hemorrhagica,  392 

diagnosis  of,  393 

treatment  of,  393 

Paget 's  disease  of  bone,  315 

Pain  in  acute  otitis  media,  450 

in  diagnosis  of  diseases  of  accessory 

nasal  sinuses,  490 
in  goiter,  779 
in  inflammation,  127 
in  postoperative  treatment,  147 
Palate,  cleft,  600 

operations  for,  582,  601 
age  and,  607 
anesthesia  in,  612 
Brown's,  607 
clamps  in,  604 
Davies-CoUey,  605 
field  of  operation  in,  609 
first  aid  in,  582 
hemorrhage  and,  607 
median  flap  shding,  607 
method  of  including  bone 
with  mucoperiosteum  in 
flap  formation,  605 
openings,  604 
paring  the  fissure  borders 

in,  609 
phonation  and,  619 
position  of  patient  in,  609 
preparation  of  mucoperios- 

teal  flaps  in,  612 
reversal     of     mucoperios- 
teum in  flap  formation, 
604 
suture  in,  613 
transplantation  of  tissue  to 
cover  palate  defects  in, 
postoperative  surgical 
correction  of,  617 
treatment  of,  non-surgical,  600 
postoperative,  616 
surgical,  601 
Paralysis,  facial,  nerve  anastomosis  for, 

689 
Paralytic  distention,  postoperative  treat- 
ment and,  151 
Parasacral  anesthesia,  115 
Parasitic  cysts  of  jaws,  553 
Parathyroid  glands,  injury  to,  in  treat- 
ment of  exophthalmic  goiter,  798 


842 


INDEX 


Parathyroid  glands,  surgical  importance 

of,  810 
Paravertebral  anesthesia,  114 
Parenchymatous  inflammation,  127 
Parotid  gland,  carcinoma  of,  radium  in 

treatment  of,  228 
Parotitis,  surgical  prognosis  and,  72 
Percy's  method  of  blood  transfusion,  200 
preparation    of    tube, 
201 
Pericementitis,  calcic,  542 

phagedenic,  542 
Pericranial    sinus,    diagnosis    of,    from 

pneumatocele  of  scalj),  278 
Perineural  anesthesia,  112 
Periosteal  cysts  of  jaws,  551 

symptoms  of,  551 
treatment  of,  551 
Periostitis,  necrosis  of  jaws  and,  649 
of  skull,  315 

diagnosis  of,  316 
prognosis  of,  316 
treatment  of,  316 
Peritoneal  adhesions,  surgical  prognosis 

and,  62 
Peritoneum,  operations  on,  wound  infec- 
tion in,  surgical  prognosis  and,  53 
Peritonitis  in  acute  dilatation  of  stomach 
in  postoperative  treatment,  156  i 

Perivascular    tissues    in     inflammation,  ' 

126 
Pernicious  anemia,  blood  transfusion  in, 

192 
Phagedenic  pericementitis,  542 
Pharynx,   carcinoma  of,   operation  for, 
663 
radium  in  treatment  of,  228 
operations  on,  513 
tumors  of,  513 

operations  for,  514 

after-treatment  in,  515 
Beck's,  515 
technic  of,  514 
vadium  treatment  of,  517 
after-treatment  in,  517 
Phlebitis,  surgical  prognosis  and,  60 
Phonation,  operation  for  cleft  palate  and, 

619 
Pineal  gland,  tumors  of,  347 

symptoms  of,  347 
treatment  of,  382 
Pleura,  injury  to,  in  treatment  of  exoph- 

thamic  goiter,  799 
Pleurisy,  surgical  prognosis  and,  55 
Plexiform  angioma  of  scalp,  285 

neuroma  of  scalp,  283 
Pneumatocele  of  scalp,  277 
diagnosis  of,  277 

from  cephalhematoma,  278 
from  meningocele,  277 
from  pericranial  sinus,  278 
from  tuberculosis  of  mas- 
toid, 278 
treatment  of,  278 
Pneumonia,  lobar,  surgical  prognosis  and, 
55 


Poisoning,  illuminating  gas,  blood  trans- 
fusion in,  192 
Polypi,  nasal,  517 

treatment  of,  517 
Pons,  tumors  of,  339 
Port-wine  stains  of  scalp,  286 
Postoperative  hyperthyroidism  and  treat- 
ment of  exophthalmic  goiter,  797 
nausea,  anesthesia  and,  42 
treatment,  139 

abdominal  distention  and,  151 
acidosis  and,  157 
acute  dilatation  of  stomach  and 
155 
chloroform       anesthesia 

and,  156 
constipation  and,  156 
diarrhea  and,  156 
peritonitis  and,  156 
prognosis  of,  157 
pyloric  spasm  and,  156 
trauma  and,    156 
treatment  of,  157 
vomiting  and,  156 
alimentary  tract  and,  141 
artificial  heat  and,  147 
bladder  and,  149 
bowels  and,  141,  149 
care  after  operation,  146 

recovery  from  opera- 
tion, "150 
choice  of  anesthetic  and,  140 
complications  and,  151 
conduct  of  operation  and,  143 
correct  diagnosis  and,  139 
diet  and,  148 
drainage  and,  144 
dressings  and,  145 
field  of  operation  and,  141 
hemorrhage  and,  151 
hiccough  and,  157 

treatment  of,  157 
intestinal  obstruction  and,  152 
mechanical,  153 
pain  in,  153 
symptoms,  153 
treatment,  153 
vomiting  in,  153 
1  mouth  and,  141 

nasopharynx  and,  141 
nausea  and,  147 
nourishment  and,  141 
operating  table  and,  142 
pain  and,  147 

paralytic  distention  and,  151 
patient's  clothing  and,  142 
position  and,  146 
pulmonary  emboHsm  and,   161 
symptoms  of,  161 
treatment  of,  161 
pulse  and,  150 
respiration  and,  150 
respiratory  tract  and,  141 
restraint  and,  146 
shock  and,  151 
temperature  and,  150 


INDEX 


843 


Postoperative  treatment,  thirst  and,  148 
thrombophlebitis  and,  159 

treatment  of,  160 
time  in  bed  and,  150 
urinary  tract  and,  142 
vomiting  and,  147 
vomiting,  anesthesia  and,  42 
Pregnancy,  anemia  complicating,  blood 

transfusion  in,  190 
Procain  as  local  anesthetic,  109 
Prognathous  lower  jaw,  567 

bilateral  resections  to  re- 
duce, 567 
Prohferous  cysts  of  jaws,  552 

treatment  of,  552 
Prostate  gland,  enlargement  of,  roentgen 

rays  in  treatment  of,  260 
Pseudoleukemia,     diagnosis     of,     from 
tuberculous    cervical    lymphadem'tis, 
699 
Pseudomembranous  inflammation,  127 
Pulmonary  compHcations,  postoperative, 
surgical  prognosis  and,  55 
embolism,  postoperative  treatment 
and,  161 
Pulse  in  abscess  of  brain  of  otitic  origin, 
470  _ 
in  erysipelas  of  scalp,  273 
in  postoperative  treatment,  150 
in  tumors  of  brain,  353 
Pulse-pressure,  surgical  prognosis  and,  32 
Punctured  wounds  of  cranial  bones,  294 

of  scalp,  268 
Purulent  infianomation,  127 
Pus  in  diagnosis  of  diseases  of  accessory 

nasal  sinuses,  491 
Pyemia,  blood  cultures  in,  134  . 
chills  in,  136 
complications  of,  136 
diagnosis  of,  136 
etiology  of,  133 
fever  in,  136 
hemorrhage  in,  136 
pathology  of,  135 
prognosis  of,  137 
symptoms  of,  136 
treatment  of,  137 
vomiting  in,  136 
Pyloric    spasm   in   acute    dilatation   of 
stomach  in  postoperative  treatment, 
156 
Pyorrhea  alveolaris,  542 
diagnosis  of,  544 
emetin  and,  546 
endameba  gingivahs  and,  543 
etiology  of,  542 
ionic  medication  and,  545 
pathology  of,  543 
prognosis  of,  544 
surgical  aspect  of,  542 
symptoms  of,  544 
treatment  of,  544 


Quinine  salts  as  local  anesthetic,  110 


B 


Radicular  odontomas  of  jaws,  555 
Rafhography,  malposed  unerupted  teeth 

and,  561 
Radiology  in  abscess  of  brain,  356 

in  tumor  of  brain,  356 
Radium,  Barlow's  experiments  with,  216 
in  carcinoma  of  breast,  225 
of  esophag-us,  228 
of  face,  220 
of  parotid  gland,  226 
of  pharjmx,  228 
of  rectum,  228 
of  stomach,  228 
of  tonsil,  228 
of  uterus,  229 
Carrel's  experiments  with,  212 
effect  of,  on  animal  and  vegetable 

life,  215 
efficiency  of,  in  mahgnant  disease, 

209 
in  epithelial  timiors,  220 
in  leukoplakia,  227 
rays  of,  direction  of,  210 
in  sarcoma  of  skull,  224 
technical  appUcation  of,  230 
in  tumors  of  jaw,  218,  219 

of  pharynx,  517 
in  warts  of  vocal  cords,  218 
Ranula,  548 

diagnosis  of,  548 
etiology  of,  548 
symptoms  of,  548 
treatment  of,  548 
V.  Recklinghausen's  diseases  of  scalp,  283 
Rectal  anesthesia,  107 
Rectum,  carcinoma  of,  radium  in  treat- 
ment of,  228 
Recurrent  larjmgeal  nerves,  injury  to,  in 
treatment  of  exophthalmic  goiter,  798 
Regional  anesthesia.  111 
Renal  disease,  surgical  prognosis  and,  32 
Resection  in  treatment  of  goiter,  784 
Respiration  in  postoperative  treatment, 

150 
Respiratory  tract,  postoperative  treat- 
ment and,  141 
Resterilizing  used  dressings,  92 
Retention  cysts  of  mucous  glands,  547 
symptoms  of,  548 
treatment  of,  548 
of  neck,  712 
Rheumatic  arthritis,  vaccines  in,  181 
diagnosis  of,  182 
dosage  in,  182 
Rib  grafts,  645 
Rigg's  disease,  542 
Riley's  appHance  for  chronic  dislocation 

of  lower  jaw,  630 
Ritter's  frontal  sinus  nasal  soimd,  496 
Rodent  ulcers  of  scalp,  289 
Roentgen  rays,  biological  action  of,  250 
in  treatment  of  carcinoma,  255 
of  disease  of  blood,  261 
of  thyroid  gland,  259 


844 


INDEX 


Roentgen  rays  in  treatment  of  enlarge- 
ments   of    prostate 
gland,  260 
of  thj-mus  gland,  260 
of  Hodgkin's  disease,  261 
of  inflammatory  diseases, 

260 
of  myoma  of  uterus,  260 
of  sarcoma,  259 
Roentgenograms  in  diagnosis  of  diseases 

of  accessory  nasal  sinuses,  490 
Roentgentherapy,  deep,  235 
accessories  in,  2-43 
Coolidge  tube  in,  235 
technic  of,  244 
transformer  in,  239 
Rubber  gloves,  use  of,  86 

tubing,  preparation  of,  90 


S 


Sarcoma  of  hypophysis,  344 

malposed  unerupted  teeth  and,  558 
of  neck,  719 

roentgen  ravs  in  treatment  of,  259 
of  scalp,  291 

diagnosis  of,  293 

from  syphilis,  276 
nodular,  291 
prognosis  of,  293 
treatment  of,  293 
warty,  293 
of  skull,  322 

diagnosis  of,  324 

from  leontiasis  ossea,  313 
from  syphilis,  318 
histology  of,  323 
myelogenous,  323 
treatment  of,  325 
radium  in,  224 
of  th3Toid  gland,  807 

diagnosis  of,  807 
treatment  of,  808 
Sauer's  spHnt,  628 
Scalp,  adenoma  of,  281 
anatomy  of,  263 
aneurj'sm  of,  arteriovenous,  283 
circoid,  285 
traumatic,  283 

treatment  of,  283 
aneurysmal  varix  of,  284 

treatment  of,  284 
angioma  of,  286 

arteriale  racemosum  of,  285 
diagnosis  of,  286 
treatment  of,  286 
cavernous,  287 
diagnosis  of,  287 
plexiform,  285 
treatment  of,  287 
angiosarcoma  of,  293 
atheromatous  cysts  of,  280 
treatment  of,  281 
avulsion  of,  270 


Scalp,    blastomycosis  of,    diagnosis    of, 
from  carcinoma,  291 
blood  cyst  of,  267,  283 

supply  of,  263 
bloodvessels  of,  diseases  of,  283 
carbuncle  of,  273 

operation  for,  274 
prognosis  of,  274 
carcinoma  of,  289 
diagnosis  of,  291 

from  blastomycosis,  291 
from  syphilis,  277,  291 
from  tuberculosis,  291 
treatment  of,  291 
cephalocele  of,   diagnosis  of,   from 

hpoma,  283 

cephalohernatoma  of,  266 

cephalohydrocele  traumatica  of,  278 

diagnosis  of,  279 

treatment  of,  280 

cold  abscess  of,  diagnosis  of,  from 

Upoma,  283 
contusions  of,  265 
cutaneous  horns  of,  281 

warts  of,  281 
cysts  of,  280 
dermoid,  280 

diagnosis    of,    from    brain 
cysts,  280 
from  cephalocele,  280 
from  lipoma,  282 
from  sebaceous  cysts, 

280 
from  serous  cysts,  280 
emphysema  of,  277 
endotheUoma  of,  293 
epithelioma  of,  289 
erysipelas  of,  272 
headache  in,  273 
prognosis  of,  273 
pulse  in,  273 
treatment  of,  273 
vomiting  in,  273 
fibroma  of,  281 
hematoma  of,  265 
deep,  265 
diagnosis  of,  267 
•        from  cephalocele,  267 
from  hernia  cerebri,  267 
from   meningocele   spuria, 
267 
subcutaneous,  265 
treatment  of,  267 
injuries  of,  265 
keloids  of,  282 

differential  diagnosis  of,  282 
treatment  of,  282 
lipoma  of.  282 

diagnosis  of,  from  cephalocele, 
283 
from  cold  abscess.  283 
from  dermoids,  282 
lupus  of,  diagnosis  of,  from  syphilis, 

276 
l>Tnphangio-endothelioma  of,  293 
IjTnphatics  of,  264 


INDEX 


845 


Scalp,  malignant  growths  of,  289 

meningocele  spuria  (traumatica)  of, 
278 
diagnosis  of,  279 
treatment  of,  280 
muscles  of,  264 
nerves  of,  265 

diseases  of,  283 

diagnosis  of,  283 
treatment  of,  283 ' 
elephantiasis  of,  283 
neurofibroma  of,  283 
plexiform  neuroma  of,  283 
von    Recklinghausen's    disease 
of,  283 
non-neoplastic  swellings  of,  277 
pneumotocele  of,  277 
diagnosis  of,  277 

from  cephalhematoma,  278 
from  meningocele,  277 
from  pericranial  sinus,  278 
from  tuberculosis  of  mas- 
toid, 278 
treatment  of,  278 
port-wine  stains  of,  286 
rodent  ulcers  of,  289 
sarcoma  of,  291 

diagnosis  of,  293 

from  syphilis,  276 
nodular,  291 
prognosis  of,  293 
treatment  of,  293 
warty,  292 
sebaceous  cysts  of,  280 

treatment  of,  281 
syphiUs  of,  274 

diagnosis  of,  274 

from  carcinoma,  277,  291 
from  lupus,  276 
from  sarcoma,  276 
tuberculosis  of,   diagnosis   of,    from 

carcinoma,  291 
tumors  of,  280 
vascular  nevi  of,  286 
wens  of,  280 

treatment  of,  281 
wounds  of,  gunshot,  271 
punctured,  268 

complications  of,  269 
Scars,  surgical  prognosis  and,  73 
Sebaceous  cysts  of  scalp,  280 

diagnosis  of,  from  dermoid,  280 
treatment  of,  281 
Secondary  anemia,  blood  transfusion  in, 

190 
Sensory  zone  of  brain,  tumors  of,  diag- 
nosis of,  333 
Septic  infections,  malignant,  132 
Septicemia,  blood  cultures  in,  134 
transfusion  in,  191 
diagnosis  of,  136 
diarrhea  in,  136 
etiology  of,  133 
fever  in,  136 
glands  in,  136 
Hippocratic  fades  in,  136 


Septicemia,  leukocytosis  in,  136 
morbid  anatomy  of,  134 
prognosis  of,  137 
pulse  in,  136 
spleen  in,  136 
sweating  in,  136 
sjTuptoms  of,  135 
treatment  of,  137 
urine  in,  136 
vaccines  in,  179 

diagnosis  of,  180 
dose  in,  180 
prognosis  of,  180 
vomiting  in,  136 
Septum  forceps,  481 
knife,  Freer's,  477 
of  nose,  deviation  of,  476 
operation  for,  476 

technic  of,  476 
treatment  of,  476 
Serous  cysts  of  scalp,  diagnosis  of,  from 

dermoid,  280 
Serums,  170 
Shock,  117 

comphcating  anesthesia,  106 
critical  level    of   blood-pressure   in, 

118 
definition  of,  117 
diagnosis  of,  121 

from  hemorrhage,  121 
etiology  of,  theories  of,  118 
acapnia,  118 
cardiac  failure,  120 
fat  embolism,  118 
nerve  exhaustion,  118 
suprarenal  exhaustion,  119 
as  exemia,  120 

postoperative  treatment  and,  151 
surgical,      blood      transfusion     in, 
191 
methods  of  combating,  123 
operations  in,  relation  to,  123 
prognosis  and,  45 

abdominal  operations  and, 

49 
age  in,  47 

brain  surgery  and,  49 
cachexia  in,  48 
intrathoracic    operations 

and,  49 
laryngeal   operations   and, 

49 
operations   on   extremities 

and,  50 
previous  nerve  exhaustion 

in,  47 
recent  severe  illness  in,  48 
sepsis  in,  48 
temperament  in,  47 
treatment  of,  122 

prophylactic,  121 
in  treatment  of  exophthalmic  goiter, 
797 
Side  chain  theory'  of  Ehrlich,  169 
Silkworm  gut,  preparation  of,  89 
Sinus,  frontal  operations  on,  498 


846 


INDEX 


Sinus,    pericranial,     diagnosis    of,   from 
pneumatocele  of  scalp,  278 
sphenoid,  operations  on,  512 
thrombosis,  mastoiditis  and,  466 
chill  in,  466 
fever  in,  466 
leukocytosis  in,  466 
S3'mi)toms  of,  466 
treatment  of,  467 
Skin,  disinfection  of,  86 

in  exophthalmic  goiter,  792 
Skull,  acromegaly  of,  311 
treatment  of,  313 
actinomycosis  of,  diagnosis  of,  from 

tuberculosis,  319 
acute  pyogenic  osteomyelitis  of,  315 
diagnosis  of,  316 
prognosis  of,  316 
treatment  of,  316 
atrophy  of,  307 

diagnosis  of,  309 
excentric,  308 

extracranial  pressure  and,  308 
intracranial  pressure  and,  307 
of  rickets  of,  308 
senile,  308 
treatment  of,  311 
cavernoma  of,  322 
chloroma  of,  325 
cholesteatoma  of,  322 
contusions  of,  294 
diagnosis  of,  294 
prognosis  of,  295 
coverings  of,  263 
echinococcus  cysts  of,  322 
treatment  of,  322 
fractures  of,  295 
of  base,  300 
comminuted,  297 
compound,  of  vault,  298 
of  external  table,  299 
fissured,  296 
hemorrhage  in,  300 
of  internal  table,  299 
prognosis  of,  303 
simple,  296 
symptoms  of,  300 
treatment  of,  303 
gigantism  of,  213 
injuries  of,   in  infants  and  young 

children,  307 
leontiasis  ossea'of,  313 

diagnosis  of,  313 

from  acromegaly,  313 
from     osteitis     defor- 
mans, 313 
from  sarcoma,  313 
treatment,  313 
mj'eloma  of,  325 
osteitis  deformans  of,  315 
osteoma  of,  320 

diagnosis  of,  321 
treatment  of,  322 
osteomyelitis  of,  308 
periostitis  of,  315 
diagnosis  of,  316 


Skull,  periostitis  of,  prognosis  of,  316 
treatment  of,  316 
sarcoma  of,  322 

diagnosis  of,  324 

from  leontiasis  ossea,  313 
from  syphilis,  318 
histology  of,  323 
myelogenous,  323 
treatment  of,  325 
radium  in,  224 
syphilis  of,  316 

diagnosis  of,  317 

from  sarcoma,  318 
from  tuberculosis,  318 
symptoms  of,  316 
tuberculosis  of,  318 
diagnosis  of,  319 

from  actinomycosis,  319 
from  glanders,  319 
from  syphilis,  318,  319 
symptoms  of,  319 
tumors  of,  320 
wounds  of,  293 
gunshot,  304 

diagnosis  of,  306 
prognosis  of,  306 
treatment  of,  306 
incised,  293 
punctured,  294 
Sluder's  tonsil  operation,  524 

Beck's  modification  of,  525 
La  P'orce's  modification  of, 
525 
Spasm,  pyloric,  in  acute  dilatation  of 
stomach  in  postoperative  treatment, 
156 
Specific  infective  inflammation,  127 
Sphenoid  sinus,  operations  on,  512 

sounds,  497 
Spinal  anesthesia,  112 

surgical  prognosis  and,  40 
Spine,  tuberculosis  of,  diagnosis  of,  from 

wry-neck,  670 
Splints,  interdental,  625 
Staphylorrhaphy,  581,  601 

compression,  601 
Stellwag's  sign  in  exophthalmic  goiter, 

792 
Sternomastoid    muscle,   division    of,    in 

treatment  of  wry-neck,  671 
Stevenson's  adenotome,  530 
Stomach,  carcinoma  of,  radimn  in  treat- 
ment of,  228 
dilatation   of,  acute,    postoperative 
treatment  and,  155 
surgical  prognosis  and,  68 
Stovain  as  local  anesthetic,  109 
Streptococcus    viridans,    dento-alveolar 

abscess  and,  536 
Stricture   of  esophagus,   esophagoscopy 

for,  765 
Stupor  in  tumors  of  brain,  353 
Subhyoid  pharyngotomy,  729 
Subungual  bursa,  hydrops  of,  550 
Subtemporal  decompression,  407 
anesthesia  in,  423 


INDEX 


847 


Subtemporal  decompression,  bone  defect 
and,  429 
cerebral  exploration  in,  432 
closure  in,  435 
dural  opening  in,  432 
extracranial  incision  in,  429 
field  preparation  in,  423 
Suppurative  arthritis,  vaccines  in,  180 
Suppurative  inflammation,  127 
Supranasal  route  in  operation  for  tumors 

of  hypophysis,  371 
Suprarenal  exhaustion  theory  of  shock, 

119 
Surgical  dressings,  disinfection  of,  91 
fever,  131 

nature  of,  131 
prognosis,  17 

accidents  and,  37 

acidosis  and,  33 

acute  bronchitis  and,  36 

dilatation  of  stomach  and, 66 
postoperative   congestion 
of  lungs  and,  55 
age  and,  25 
alcoholism  and,  30 
anemia  and,  36 
anesthesia  and,  38 

effects    of,    on    immunity 
factors,  42 
on  kidneys,  41 
on  liver,  41 
on  lungs,  42 
on  nervous  system,  42 
remote,  41 
postoperative  nauseaand,42 
vomiting  and,  42 
artificial  menopause  and,  71 
blood-pressure  and,  32 
bronchitis  and,  55 
bronchopneumonia  and,  55 
chloroform  and,  40 
complications  and,  37 
constitution  and,  28 
cystitis  and,  69 
diabetes  and,  32 
embohsm  and,  57 
air,  59 
fat,  59 
ether  and,  38 

general  factors  influencing,  25 
heart  disease  and,  31 
hemophilia  and,  34 
hemorrhage  and,  43 
injury  to  ureter  and,  69 
intestinal  auto-intoxication  and, 

34 
jaundice  and,   35 
lobar  pneumonia  and,  55 
nerve  injuries  and,  71 
neurotic  temperament  and,  28 
nitrous  oxide  and,  40 
obesity  and,  30 
oxygen  and,  40 
parotitis  and,  70 
peritoneal  adhesions  and,  62 
phlebitis  and,  60 


Surgical  prognosis,  pleurisy  and,  55 

postoperative  intestinal  fistulas 
and,  70 
obstruction  and,  64 
neuroses  and,  73 
pulmonary     complications 

and,  55 
susceptibility  to  fatigue,  73 
ventral  hernia  and,  66 
pulse-pressure  and,  32 
renal  disease  and,  32 
scars  and,  71 
sex  and,  28 
shock  and,  45 

abdominal  operations  and, 

49 
acute,  blood  transfusion  in, 

191 
age  in,  47 

brain  surgery  and,  49 
cachexia  in,  48 
intrathoracic    operations 

and,  49 
laryngeal  operations  and, 

49 
operations   on   extremities 

and,  50 
previous  nerve  exhaustion 

in,  47 
recent  severe  illness  in,  48 
sepsis  in,  48 
•temperament  in,  47 
spinal  anesthesia  and,  40 
statistics  in,  17 
wound  infection  and,  50 

in  accidental  wounds,  54 
in  gynecological  operations, 

52 
in  operations  on  breast,  51 
on  face,  51 
on  head,  51 
for  hernia,  51 
on  intestinal  tract,  52 
on  neck,  51 
on  peritoneum,  53 
in  war  wounds,  55 
Sweating  in  exophthalmic  goiter,  792 
Syphilis  of  brain,  404 

diagnosis  of,  404 
treatment  of,  405 
of  neck,  695 

diagnosis  of,  696 

from  actinomycosis,  695 
from   tuberculous    cervical 
lymphadenitis,  699 
treatment  of,  697 
of  scalp,  274 

diagnosis  of,  274 

from  carcinoma,  277,  291 
from  lupus,  276 
from  sarcoma,  276 
of  skull,  316 

diagnosis  of,  317 

from  sarcoma,  318 
from  tuberculosis,  318 
symptoms  of,  316 


848 


INDEX 


Tachycardia    in    exophthalmic    goiter, 

789 
Technical  efficiency,  77 

arrangement  of  operating  room 

ami,  78 
automatic  action  and,  78 
concentration,  77 
constancy  of  working  plan  and, 

77 
instruments  and,  77 
limited    number    of    assistants 

and,  77 
preparation  and,  77 
system  and,  77 
Teeth,  malposed  unerupted,  558 
carcinoma  and,  558 
diagnosis  of,  560 
headache  and,  558 
neuralgia  and,  558 
neurasthenia  and,  558 
pathological  significance  of, 

558 
radiography  and,  561 
sarcoma  and,  558 
treatment  of,  561 
Temperature  in  postoperative  treatment, 

150 
Temporal  lolies  of  brain,  tumors  of,  325 
Teratomas  of  jaws,  552 

of  neck,  711 
Tenninal  infections,  133 
Tetany,  thyroidectomy  and,  810 
Thirst,  postoperative  treatment  and,  148 
Thoracic  duct,  injuries  of,  690 
Thrombophlebitis,    postoperative   treat- 
ment and,  159 
Thrombosis  of  intracranial  blood  sinuses, 
401 
diagnosis  of,  401 
treatment  of,  402 
Thymectomy,  824 
anesthesia  in,  825 
technic  of,  824 
Thymus  gland,  anatomy  of,  822 

enlargement  of,  roentgen  rays 

in  treatment  of,  260 
function  of,  822 
hypertrophy  of,  822 
diagnosis  of,  823 
thj'mectomy  in,  824 
treatment  of,  824 

x-ray  in,  823,  824 
internal  secretion  and,  822 
physiology  of,  821 
surgery  of,  821 
thyroid  gland  and,  823 
Thyreotomy,  728 
Thyreotoxicosis,  813 
Thyroid  gland,  adenoma  of,  813 
carcinoma  of,  807 
diagnosis  of,  807 
treatment  of,  807 
diseases   of,    roentgen    rays    in 
treatment  of,  259 


Thyroid  gland,  electrical    conductivity 
in  its  relation  to,  819 
hyperplasia  of,  812 
mechanism   of   nervousness   in 
infections  in  relation  to,  817 
sarcoma  of,  807 

diagnosis  of,  807 
treatment  of,  808 
thymus  gland  and,  823 
murmur  in  exophthalmic  goiter,  789 
Thyroidectomy  in  exophthalmic  goiter, 
802 
tetany  and,  810 
Tinnitus,  abscess  of  brain  and,  349 

tumors  of  brain  and,  349 
Tongue,  tumors  of,  658 

operation   for,    after-treatment 
in,  661 
Kocher's,  659 
methods  of,  658 
Tonsillectomy  in  tumors  of  tonsil,  662 
Tonsillitis,   operations   for  deviation   of 

nasal  septum  and,  483 
Tonsils,  carcinoma  of,  operation  for,  662 
radium  in  treatment  of,  228 
clamp,  533 
diseases  of,  518 

treatment  of,  521 
operations  on,  522 

accidents  in  anesthetics  in,  522 
dissection,  531 

technic  of,  531 
Sluder's,  524 

Beck's  modification  of,  525 
La  Force's  modification  of, 
525 
surgical    correction    of   palatal 
and   pharyngeal  defects   fol- 
lowing, 620 
technic  of,  524 
pillar  retractor,  531 
snare,  529 
surgical  diseases  of,  661 

operations  for,  661 
tonsillectomy  in,  662 
Topical  application  of  anesthetic.  111 
Torticollis,  669.     See  Wry-neck. 

spasmodic,  673.     See    Wry-neck, 
spasmodic. 
Toxemia,  Iilood  transfusion  in,  191 
Trachea,    collapse   of,    in   treatment   of 
exophthalmic  goiter,  798 
injuries  of,  690 
operations  on,  727 
Tracheotomic  bronchoscopy,  756 
Tracheotomy,  732 
Transfusion  of  blood,    187.     See  Blood 

transfusion. 
Transillumination   in   diagnosis   of   dis- 
eases of  accessory  nasal  sinuses,  491 
Transsphenoidal  methods  of  operation  in 

tumors  of  hypophysis,  370 
Traumatic  aneurysm  of  scalp,  283 
cephalohydrocele  of  scalp,  278 
fever,  aseptic,  132 
inflammation,  127 


INDEX 


849 


Tremor  in  exophthalmic  goiter,  790 
Trench  mouth,  546 

treatment  of,  547 
Trismus,  649 

Tropocain  as  local  anesthetic,  109 
Tuberculosis  of  cervical  glands,  diagnosis 
of,  from  wry-neck,  670 
of  mastoid,  diagnosis  of,  from  pneu- 
matocele of  scalp,  278 
ofscalp,  diagnosis  of,  from  carcinoma, 

291 
of  skull,  318 

diagnosis  of,  319 

from  actinomycosis,  319 
from  glanders,  319 
from  syphihs,  318,  319 
symptoms  of,  319 
of  spine,    diagnosis    of,    from   wry- 
neck, 670 
Tuberculous  cervical  lymphadenitis,  699 
diagnosis  of,  699 

from  carcinoma,  700 
from    Hodgkin's    dis- 
ease, 699 
from  leukemia,  699 
from  pseudoleukemia, 

699 
from  syphilis,  699 
excision  of  glands  of  neck 

in,  701 
treatment  of,  700 
operative,  701 
meningitis,  404 

diagnosis  of,  404 
treatment  of,  404 
Tumors  of  brain,  ataxia  and,  351 

cerebrospinal  fluid  and,  354 
choked  disk  in,  352 
convulsions  in,  353 
deafness  and,  349 
diagnosis  of,  327 
disorientation  and,  351 
dysmetria  and,  351 
headache  in,  352 
lumbar  puncture  and,  354 
nystagmus  and,  350 
pulse  in,  353 
radiology  in,  356 
signs  of,  352 
stupor  in,  353 
symptoms  of,  352 
tinnitus  and,  349 
treatment  of,  358 
vertigo  and,  351,  353 
vomiting  in,  353 
of  carotid  gland,  720 

diagnosis  of,  721 

symptoms  of,  721 

treatment  of,  721 

of  central  gray  matter  of  brain,  336 

cerebellar,  treatment  of,  364 

of  cerebellopontine  angle,  338 

treatment  of,  364 
of  cerebellum,  337 
of  cerebral  peduncles,  340 
of  corpora  quadrigemina,  340 


Tumors  of  corpus  callosum,  337 

epitheUal,  radium  in  treatment  of, 

220 
of  esophagus,  esophagoscopy  for,  765 
of  frontal  lobes,  diagnosis  of,  332 
of  Gasserian  ganglion,  removal  of, 

383 
of  hypophysis,  340 

treatment  of,  367 
of  jaw,  radium  in  treatment  of,  218, 

219 
of  medulla  oblongata,  339 
of  motor  zone  of  brain,  diagnosis  of, 

333 
of  neck,  710 
benign,  714 

treatment  of,  717 
malignant,  718 

treatment  of,  722 
of  occipital  lobe,  336 
of  pharynx,  513 

operations  for,  514 

after-treatment  in,  515 
Beck's,  515 
technic  of,  514 
radium  treatment  of,  517 

after-treatment    in, 

517 
technic  of,  517 
of  pineal  gland,  347 

treatment  of,  382 
of  pons,  339  - 
of  scalp,  280 
sensory  zone  of  brain,  diagnosis  of, 

333 
of  skull,  320 

of  temporal  lobes,  diagnosis  of,  325 
of  tongue,  658 
Turmschadel,  391 

Typhoid  fever,   hemorrhages  in,   blood 
transfusion  in,  190 


U 


Ulcer,  varicose,  vaccines  in,  186 

Ulcers,  rodent,  of  scalp,  289 

Unchromicized  catgut,  preparation  of,  89 

Unerupted  teeth,  malposed,  558 
carcinoma  and,  558 
diagnosis  of,  560 
headache  and,  558 
neuralgia  and,  558 
neurasthenia  and,  558 
pathological   significance 

of,  558 
radiography  and,  561 
sarcoma  and,  558 
treatment  of,  561 

Ureter,  injury  to,  surgical  prognosis  and, 
71 

Urinary  tract  in  postoperative  treatment, 
142 

Uterus,  carcinoma  of,  radium  in  treat- 
ment of,  229 


850 


INDEX 


Uterus,  myoma  of,  roentgen  rays  in  treat- 
ment of,  260 
UxTila,  carcinoma  of,  operation  for,  663 


Vaccines,  163,  170 

bacterial,  administration  of,  178 
making  pure  cultures,  175 
preparation  of,  174 

Wright's  method,  176 
sensitized,  178 
in  carbuncle,  184 
definition  of,  170 
Ehrlich's  side  chain  theory,  169 
in  empyema,  185 
in  erysipelas,  185 
in  furuncle,  182 
in  gonorrheal  arthritis,  181 
history  of,  168 
in  osteomyelitis,  185 
preparation  of,  general  priciples  of, 

170 
in  rheumatic  arthritis,  181 
diagnosis  in,  182 
dosage  in,  182 
in  septicemia,  179 
diagnosis  of,  180 
dosage  in,  180 
prognosis  of,  .180 
in  suppurative  arthritis,  180 
in  varicose  ulcer,  186 
Varicose  ulcers,  vaccines  in,  186 
Vascular  nevi  of  scalp,  286 
Vasomotor  symptoms  in  exophthalmic 

goiter,  792 
Ventral  hernia,   postoperative,   surgical 

prognosis  and,  68 
Ventricles  of  brain,  puncture  of,  385 
Vertigo  in  abscess  of  brain  of  otitic  origin, 
470 
in  infectious  labyrinthitis,  463 
in  tumors  of  brain,  353 
Vincent's    method    of   determining   the 
moss  grouping  of  blood  in  blood  trans- 
fusion, 199 
Vocal  cords,  warts  on,  radium  in  treat- 
ment of,  218 
Vomer,  treatment  of,  in  operations  for 

harelip,  590 
Vomiting  in  acute  dilatation  of  stomach 
in  postoperative  treatment,  156 
complicating  anesthesia,  105 
in  erysipelas  of  scalp,  273 
in  infectious  labyrinthitis,  463 
in  otitic  meningitis,  468 
postoperative,  anesthesia  and,  42 

treatment  of,  147 
in  pyemia,  136 
in  tumors  of  brain,  353 
von  Graefe's  rign  in  exophthalmic  goiter, 

791 
von  Recklinghausen's  disease  of  scalp, 
283 


W 

War  wounds,  infection  in,  surgical  prog- 
nosis and,  55 
Warts,  cutaneous,  of  scalp,  281 

on  vocal  cords,  radium  in  treatment 
of,  218 
Wehnelt  radiometer,  246 
Wens  of  scalp,  280 
Word  blindness  in  abscess  of  brain  of 

otitic  origin,  470 
Wound  infection  in  gynecological  opera- 
tions, surgical  prognosis  and, 
52 
in  operations  on  breast,  surgical 
prognosis  and,  51 
on  face,  surgical  prognosis 

and,  51 
on  head,  surgical  prognosis 

and,  51 
for  hernia,   surgical  prog- 
nosis and,  51 
on  intestinal  tract,  surgical 

prognosis  and,  52 
on  neck,  surgical  prognosis 

and,  51 
on     peritoneum,     surgical 
prognosis  and,  53 
Wounds,  accidental,  infection  in,  surgical 
prognosis  and,  54 
infection  of,  bacteria  causing,  82 
healing  of,  128 

by  first  intention,  128 
granulation,  129 
primary  union,  128 
by  second  intention,  129 
of  scalp,  gimshot,  271 

punctured,  268 
of  skull,  293 

gunshot,  304 
incised,  293 
punctured,  294 
war,  infection  in,  surgical  prognosis 
and,  55 
Wright's    method    of    preparation     of 

bacterial  vaccines,  176 
Wry-neck,  simple,  669 

diagnosis  of,  669 

open  division  of  sternomastoid 

muscle  for,  671 
subcutaneous  division  of  sterno- 
mastoid muscle  for,  67 1 
spasmodic,  673 

division  of  cervical  nerves  for, 
673 
of  rotating  muscles  for,  673 
Kocher's  operation  for,  673 
treatment  of,  673 


X-RAYS.     See  also  Radiology,  Roentgen 
rays  and  Roentgentherapy 
in  hypertrophv  of  thymus  gland, 
823,  824 . 


